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In the early days of sex therapy, it was commonly assumed that most sex problems had social or psychological origins - inhibitions due to guilt or shame, performance anxiety, or plain ignorance about sex. Then came Viagra in the 90s. ‘Performance anxiety’ or not, millions of men found that their erectile problems disappeared with a little blue pill, and sex therapy hasn’t been the same since. Today, consumers and doctors alike are now much more savvy about the possibility of physical conditions underlying sexual dysfunction.
But there are a couple of exceptions – IMPORTANT exceptions. At IPG, we regularly talk to people who have been told by their doctors that their sexual dysfunction is ‘all in their head’ when they actually have medical problems. Here are the two sexual problems most commonly misdiagnosed by physicians and psychotherapists untrained in sexual science:
LOW TESTOSTERONE IN MEN
The FDA estimates that 4 to 5 million American men may suffer from low testosterone, but only 5 percent are currently receiving treatment. As men get older, they naturally produce less testosterone, and this is sometimes referred to as ‘andropause,’ or ‘male menopause. But sometimes testosterone levels fall precipitously below the normal range in aging men, and there are a number of medical conditions that can cause low testosterone in younger men as well.
Several studies have shown a link between low testosterone, high cholesterol, and heart attacks. Men with low testosterone also tend to be heavier and more prone to Type 2 diabetes. While the causal relationship between these conditions is disputed, there is research showing that men who take low doses of testosterone injections, gel, or patches have reduced cholesterol and risk of heart attack, less body fat and greater muscle strength (Note: testosterone PILLS are not recommended, as they have been associated with a number of medical problems).
So what does this have to do with sex? Testosterone is the main force behind sex drive in both men and women. Low sex drive and erectile dysfunction – as well as increased irritability or depression, fatigue, reduced muscle mass, inability to concentrate, and osteoporosis – are symptoms of low testosterone. In fact, in our practice when we see men for whom the PDE-5 inhibitors like Viagra have not worked, it is frequently because the underlying cause of their erectile dysfunction is low testosterone.
Unfortunately, most psychotherapists, primary care doctors, and even many urologists have outdated information about testosterone. Many do not know the symptoms of low testosterone; some know only of the relatively dangerous pill form of testosterone; others assume that testosterone affects only sex drive and not erectile dysfunction. Physicians may test only for total testosterone levels, when at least two types of testosterone testing is necessary for accurate diagnosis, or may not have their patients tested in the morning, which is standard. And unless a doctor is trained in sexual medicine, he or she probably doesn’t know that testosterone replacement is often recommended for men who are in the bottom third of the ‘normal’ reading for t-levels, not just for men whose values fall below the scale.
The really upsetting thing about this is that testosterone replacement not only corrects sexual problems, but may be crucial in other health issues as well. In 2007, studies reported at international endocrinological meetings and journals (see, among other sources, www.WebMD.com for these articles) showed that men over 50 with low testosterone had a 33% increased risk of death over other men that could not be explained by smoking, drinking, physical activity level or pre-existing diseases.
What does it do to a man when he has low sex drive and/or problems with erections, even with a PDE-5 inhibitor, and he is told his problem is ‘in his head?’ Often, he blames himself for his problems, feels even more of a failure or incompetent, and eventually may withdraw from sex altogether. If he is in a relationship, his partner may personalize the situation and feel unattractive and undesirable, or may be angry at what is seen as sexually withholding behavior. Secondary sexual problems like premature ejaculation may develop from the psychological stress. Men with low testosterone, and their partners, often need psychotherapy to deal with the consequences of living a long time with an undiagnosed medical condition.
GENITAL PAIN/PAINFUL PENETRATION IN WOMEN
The second commonly misdiagnosed sexual ailment is genital pain in women, usually pain associated with sexual intercourse or other vaginal penetration. Women who present this problem to their psychotherapists, primary care physicians, and even their gynecologists are commonly told that they have a ‘sexual phobia.’
But whereas it was once thought that such pain was psychogenic in origin, it is now known that in most cases the culprit is a medical syndrome called vulvodynia. It is estimated that 15% of women will have vulvodynia at some time in their lives. Symptoms can come on suddenly or develop gradually, often before the age of 25 but sometimes not until middle age, and they can come and go mysteriously or last a lifetime. The symptoms of vulvodynia are described as searing or shooting pains when pressure is placed on the sensitive tissues; it has been compared to pouring acid on an open wound. For many women, the pain is localized at the opening of the vagina – called the vulvar vestibule – but for others it is located more deeply. Some women only experience this pain during vaginal penetration, but for others common activities like exercise or even just wearing jeans may be difficult.
Just as testosterone deficiency in men can be caused by a variety of medical conditions, there are a number of different types of vulvodynia. Some women seem to have problems blocking their body’s inflammatory response, so that when they get an infection, the inflammation never goes away. Others are prone to chronic yeast infections, and still others seem to have an overabundance of nerve endings in the vulvar vestibule. Some gynecologists believe that oral contraceptives predispose women to vulvodynia. Just as the causes of vulvodynia are varied, so is the treatment, which can include prolonged treatment for chronic yeast infections, medications to block nerve sensations, physical therapy, and in extreme cases, surgery.
Unfortunately, the typical woman suffering from this disease sees an average of six doctors before someone finally acknowledges she has a medical condition. By this time, she may have actually BECOME phobic about sex – let’s face it, having penetration feel like being stabbed by a thousand sharp knives can give you a powerful aversive reaction to sex. And if she is in a relationship, the condition has doubtless wreaked havoc, especially since both she and her partner have been told that pain isn’t ‘really’ there. The woman with vulvodynia that has gone undiagnosed for a long time usually needs therapy for the results of the misdiagnosis, not the condition itself.
WHAT TO DO IF YOU THINK YOU MAY HAVE ONE OF THESE PROBLEMS
If you think you may have one of these problems, the smartest thing you can do is seek a consultation with a sex therapist (the American Association for Sex Educators, Counselors, and Therapists has a list of certified sex therapists at aasect.org). Certified sex therapists can help with the diagnosis, and they usually have lists of urologists and gynecologists who are trained in sexual medicine and who know how to test for and treat these conditions. And even if you do have low testosterone or vulvodynia, you and/or your partner may have developed other problems for which you will need psychological help. A sex therapist, who is always trained in general psychotherapy and couples counseling as well, can address these problems with you.
Unfortunately, seeing your own urologist, gynecologist, or primary care physician may not be the answer – most misdiagnosis is actually done by health care professionals who are hopelessly out of date in their information and may lead you to believe your condition is all ‘mental’ rather than medical. If you do choose to go to a medical doctor first, make sure you ask the health care professional you are considering if he or she has been trained in sexual medicine. And, if after seeing a doctor you are told it is ‘all in your head’ – go get a second opinion. Many of the sexual and psychological problems we see in people with low testosterone or vulvodynia could have been avoided with early, accurate diagnosis.
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