Thursday, September 4, 2014

A Few Words About Sex

Sex remains a poorly studied and controversial topic.  It is a powerful interpersonal and cultural force.   Many ideas that originated with Freud are considered outmoded and yet when I have attended seminars that I thought might lead to ways to advance my knowledge in this area, they seemed like a dead end.  In fact, at the last seminar I attended I asked the speaker about experts in sexual consciousness he referred me to a psychoanalyst who I had corresponded with but who had since died.  The only real innovation in the area has been sexual compulsivity or sexual addiction.  Several authors write about this as though it is an actual disorder.  There have been the compulsory brain imaging studies showing activation of the reward center.  I have reservations about defining an addiction when so little is known about the baseline sexual consciousness of men and women.  It is against that backdrop that I watched two films by von Trier - both of them with the title Nymphomaniac.

After some deliberation let me say that I am not recommending that anyone watch these films.  At the very minimum they are highly controversial and they contain images that will be regarded as highly offensive or disturbing to many if not most people.  The point of this post is to illustrate how the basic storyline of these films brought me back to an issue that I have been pointing out for years, that psychiatry is no longer focused on this area of human experience even though we diagnose and treat these problems all of the time.  In many ways reading Kandel's book The Age of Insight highlights how there were more enlightened conversations about these issues in early 20th century Vienna, than I have seen anywhere during my professional career.   The public discourse is abysmal.

I was familiar with von Trier's work from an earlier film Antichrist, a film that I suppose in a very basic way was a psychotic repudiation of genital sex.  Like most things it popped up on my Netflix screen as I was getting ready to cycle.  Let me preface this post by saying that this is not a review of these films.  From what I can tell the film has been exhaustively reviewed.  The Netflix rating was a meager 2.9 stars.  Even informal reviews usually adhere to a thumbs up/thumbs down convention.  This is one of those films that is not conventional in that sense.  There are few people that would be very enthusiastic about this film based solely on content.   It is difficult to watch.  It is depressing, desolate, and in some cases violent.  It is a film that you would not necessarily recommend or even say that you had watched because it would invite inferences about your character or taste.  It may be an ideal backdrop for the trajectory of the main character and her sexual experiences in the  film.

The storyline is basic enough.  A middle aged man finds a woman who was apparently beaten up and left in an alleyway.  It is night time and lightly snowing at the time.  The alleyway is surrounded by brick walls and there is an impression that it is an impoverished part of the city.  The man offers to call for medical help but she declines.  She accepts his offer to go back to his apartment.  When she is more comfortable, she relates her history of compulsive sexual behavior in a series of eight vignettes with titles that seem interwoven with observations and stories from the man who appears to be helping her.  These stories are the main content of both films.

The stories all have the common elements of compulsive sexual behavior.  We start to learn that the chief protagonist Joe (Charlotte Gainsborough), made a conscious decision about this lifestyle at an early age.  We get to known her parents, her interactions with them and witness her father's death.  We see her embark on a vigorous program of engaging as many sexual partners per day as possible.  I think the number over much of the film that could have covered 15-20 years of her life was 8-10 men per day.  We witness some of the logistics when some of these men meet in her apartment and a scene where one of the men leaves his wife and his wife shows up at Joe's apartment with her children and is very agitated.  She angrily details the cost of  extramarital sex for the family.  Practically all of these scenes are difficult to watch.  We observe Joe over time as she becomes exhausted and eventually physically ill and debilitated, presumably from the excessive sexual behavior.  Whether or not she contracts sexually transmitted diseases is never made explicit, but we see rashes that do not heal and she describes bleeding from the genital area.  We also see her physically injured as a result of sadomasochistic behavior.  We watch her struggle emotionally.  The basic idea at the outset was not to develop any emotional attachments and to have as much sexual intercourse as possible.  Sex strictly for the sake of sex.  There are critical times during her life when that does not happen and attachments, jealousy, and envy happens and we see how she deals with these developments.  Near the end she is psychologically devastated, trapped and alone because of the sexual compulsion.  At the end, we have come full circle and realize how one of these emotional involvements has resulted in her being beaten and left in the alley.   There is additional drama at the end that I will not disclose.  If you can watch the entire sequence of these films, you deserve to discover that for yourself.

Films like Nymphomaniac are thought provoking and if you like your thoughts provoked that could lead you to give it a thumbs ups.  I have already listed my criteria for cinema as good entertainment and good acting and the film meets some of those standards.  As I thought about the content, my first thought had to do with the fact that this film was written by a man, so it is really a man's estimate of the sexual consciousness of a woman.  Strictly speaking, it is impossible for any one of us to understand the conscious state of another human being.  The thought experiment from consciousness researchers is typically, my experience of the color red is not your experience of the color red.  It is interesting to contemplate whether there might be a larger gap in understanding the sexual experience of the opposite sex.  People may argue that observations of dating and sexual behavior, anatomy and fairly crude mental and physiological data allow us to make reasonable estimates, but I would say this is more likely conjecture than the reconstruction of an actual conscious experience.  Since there is so little scientific evidence about this, the area is highly politicized.  Experts frequently talk about stereotypes of sexual behavior and the theories about why they occur.  Any attempts at discussion may break down to personal anecdotes supporting these political approaches that nobody wants to hear.   There are probably any number of reviews available online that will examine Joe's behavior from these perspectives.  Many of these arguments can come down to existential and moral dilemmas and what side of these arguments an observer happens to take.  And there is always the artistic argument that reality is relevant insofar as it may be part of the beholder's experience (see Kandel).

We get to know the man who seems to have saved Joe.  His name is Seligman (Stellan Skarsgård).  He is a self-described asexual man who gives the impression that he is an ascetic with far too much time on his hands.  His associations to some of Joe's stories often has a level of analysis that you could only get in a college classroom by a professor who is an acknowledged expert in his field. That level of sterile intellectual analysis seems consistent with his self described asceticism.   He seems to be different from the numbers of other men that Joe has encountered.  A key question is whether or not Seligman can interact with Joe in a non-sexual manner, although the obvious question is whether that can occur if a man is calmly listening to the sexual history of a self professed nymphomaniac for a number of hours.  That issue does not get resolved until the final moments of the film and I am sure that many film goers will find it controversial and suggestive of motivations on the part of the director and writer.

As as psychiatrist and a physician I naturally think about the implications of this movie.  Have I seen people with this problem?  Do I think this problem exists?  Have I been able to help people with all of the variations in between?  Are there implications for the training of psychiatrists and physicians?  As a first year medical student, I was exposed to a course that was described as cutting edge at the time.  It was devised and taught by a psychiatrist who had been brought  to my medical school expressly to teach this course.   It consisted of a surprisingly dry curriculum about the importance of taking a sexual history, videos of sexual behavior with group discussions, and lectures on how to address some very basic sexual problems.  It always struck me as the "birds and the bees" talk that your parents gave you at the end of elementary school but with better audiovisuals.  It seemed shockingly unsophisticated relative to some of the theories of the day.  The timing was also wrong.  Taking 30 minutes to do a detailed sexual history is not going to work when you start rotating through acute care medical and surgical settings.  Knowing enough medicine and psychiatry and practicing in an ambulatory care setting seem like better prerequisites.  A course like that is inadequate preparation for what occurs in those clinic settings.  The mechanics are irrelevant.  The focus is all intrapsychic and interpersonal, helping the person process that information and adapt.  A focus on the mechanics of sex,  either in the sexual history or sexual education in school really seems to miss the mark.  All of the discussion of mechanics even with the recent details of how the ventral striatum is activated during sexual behavior seems to marginalize the meaning of sexual behavior and how it influences the entire conscious state of a person.  Whether Joe's story is accurate or not, the common experience of sexual behavior organizing one's conscious state probably makes this story believable for most people.

The issue of whether of not nymphomaniacs exist is certainly another issue for psychiatry.  The diagnostic manual lists no similar term and no reference to the equivalent condition in the film - sexual addiction.  In some circles, sexual addiction is seen as a behavioral equivalent of substance use disorders.   The existing sexual dysfunctions available for diagnosis include problems with hypoactive sexual desire, arousal and orgasms.  Hypersexual disorder is not an option and Grant and Black explain:

"During DSM-5 deliberations, there was some controversy about the possibility of including hypersexual disorder, which is characterized by sexual behavior that is excessive or poorly controlled (commonly referred to as either "sex addiction" or "compulsive sexual behavior") and paraphilic coercive disorder, which consists of a sexual preference for coerced sexual activity (i.e. rape).  After considerable discussion and input from fellow APA members, the decision was made not to include these disorders in DSM-5." (p. 274)

A current Medline review shows that the research in this area is thin considering that there are experts out there who are treating sexual addiction or sexual compulsivity and there are several instruments that are designed to gather that data.   I also can't help but think that there are more cases that are under the epidemiological radar.  By that I mean the cases that present to psychoanalysts.  Some of the most fascinating areas that I studied as a resident were the different approaches to psychoanalysis, particularly the differences between Kohut and Kernberg.  Kohut's paper called "The Two Analyses of Mr Z." was particularly interesting because the presenting symptom was compulsive sexual behavior.  The symptom did not respond to traditional psychoanalysis but required Kohut to modify the technique and he used this as an example of his new self-psychology approach in psychoanalysis.  So a question for the analysts out there, I know that many analysts treat focal sexual symptomatology out there and eschew the DSM categorical approach to sexual behavior.  Are there psychoanalytical papers written about hypersexuality in general and is it a problem frequently seen in psychoanalytic practice?  The Psychodynamic Diagnostic Manual has the following commentary on the subject of the categorical (DSM) classification of sexual disorders:

"Sexual inclinations and experiences are sufficiently diverse among human beings that we urge caution in diagnosis.  In this area we are particularly uncomfortable with the categorical depiction of "disorders" in the DSM.  Especially in the area of paraphilias, it becomes easy to pathologize behavior that may simply be idiosyncratic.  In contrast to categorizing specific acts as inherently pathological irrespective of context and meaning, we recommend a thoughtful assessment of subjective factors, meanings, and contexts of variant sexualities...." (p. 126)

The diagnosis of Hypersexual Disorder was listed in the online proposed DSM-5 as a paraphilic disorder but it did not make the final cut.   There was a note posted that it would be included in "Section III" conditions for further study, but in the final version it was not listed there either.  It would appear that there is little guidance from either the DSM or PDM camp on this disorder.

I had originally planned to include a new graphic here summarizing the imaging results from studies of human behavior, but I am having some difficulty getting the original papers and images.  For anyone interested in that list of references you can find them here.  A recent paper in Science, raises some serious questions about what reward center activation really means (see Donoso, et al).  In this paper the authors demonstrate that reward center activation can occur with a purely cognitive task and seems to function in a way to continue to make correct choices.  That raises some questions about conventional approaches to reward center activation and what it means in the study of human sexual behavior but also addictions of all types.  How much reward center activation is purely due to making a "correct" choice and what does that mean in the case of an addiction or in the cases of normal function like eating, drinking, or sexual behavior?

In terms of clinical practice, I have treated hundreds of people with hypersexuality, socially inappropriate sexual behavior, and victims of sexual assault.  They were almost all due to mood disorders (mostly mania), neurocognitive disorders, chronic intoxication states associated with addictions, medication side effects (primarily medications used to treat Parkinson's Disease), or the effects of various forms of sexual violence.  I have fielded a lot of questions on the whole notion of sexual addiction, especially in chemical dependency treatment settings where compulsive behaviors are viewed as behavioral addictions.  I have never really encountered anyone describing a problem similar to what is portrayed in Nymphomaniac.   There is always a strong selection bias in clinical practice and for a long time, I assessed and treated people with severe mental illnesses and addictions.   The hypersexuality in these cases usually had causes that any psychiatrist could diagnose and hopefully treat.   My read of the psychoanalytic and family therapy literature suggests that there are cases that are independent of the etiologies that I have seen and many of them have intrapsychic/interpersonal and social etiologies.  Apart from individual case presentations by psychoanalysts and psychotherapists it is very difficult to see this as a widespread problem.  That seems to happen in other areas like Intermittent Explosive Disorder.  I have not seen a single case in 28 years and yet there it sits in the DSM-5.

This is probably another area in psychiatry that will require a lot of data and more research to resolve.  People often take offense to the idea of more research as a standard answer, but it should be clear that when it comes to sex, the approaches are largely anecdotal and it seems like an area that most people avoid thinking about in any scientific manner.

George Dawson, MD, DFAPA

Black DW, Grant JE.  DSM-5 Guidebook - The Essential Companion To The Diagnostic and Statistical Manual of Mental Disorders.  American Psychiatric Publishing, Washington, DC.  2014.  p.274.

Kafka MP.  Hypersexual Disorder: A Proposed Diagnosis for DSM-5.  Arch Sex Behav (2010) 39: 377–400.

"There are significant gaps in the current scientific knowledge base regarding the clinical course, developmental risk factors, family history, neurobiology, and neuropsychology of Hypersexual Disorder.  Empirically based knowledge of Hypersexual Disorder in females is lacking in particular."

Kandel ER.  The Age of Insight - The Quest to Understand the Unconscious in Art, Mind, and Brain.  Random House, New York, 2012. p. 394.

Kohut H. The two analyses of Mr. Z.  Int J Psychoanal. 1979;60(1):3-27. PubMed PMID: 457340.

PDM Task Force.  Psychodynamic Diagnostic Manual.  Alliance of Psychoanalytical Organizations.  Silver Spring, MD.  2006. p. 126

Donoso M, Collins AG, Koechlin E. Human cognition. Foundations of human reasoning in the prefrontal cortex. Science. 2014 Jun 27;344(6191):1481-6. doi: 10.1126/science.1252254. Epub 2014 May 29. PubMed PMID: 24876345.

Supplementary1:  This post may be modified as more data becomes available.  I just had to move on.

Supplementary 2:  Since there are apparently no conferences I had this idea for a conference based on this post to put sex back into psychiatry.  The conference would consist of the following elements:

1.  Update on the current epidemiology of sexual behavior.
2.  Review of the physiology and neuroendocrinology of sexual behavior.
3.  The neurobiology of the human sexual response.
4.  Brain imaging of the human sexual response.
5.  The sexual consciousness of men and women.
6.  An approach to useful clinical classifications across the DSM-PDM spectrum.
7.  Clinical approaches to identifying sexual problems and normal sexual function.
8.  Approaches to treatment across the DSM-PDM spectrum: disorders to focal problems.

Let me know if you can think of other topics, I am trying to get people interested in putting this conference together right now.


  1. In 1984 a calligrapher friend made a little poster for me that quotes Anglican bishop Mervyn Stockwood:

    "A psychiatrist is a man who goes to the Folies Bergére and looks at the audience."

    I also studied Kohut and Kernberg in my residency, and I agree "there were more enlightened conversations about [sexual] issues in early 20th century Vienna, than I have seen anywhere during my professional career. The public discourse is abysmal." And I too have never seen a case of Intermittent Explosive Disorder that wasn't better explained as a sign of another problem.

  2. I love that quote. I think I'll steal it and update it with "Scores" or "Spearmint Rhino". Not as classy, but people will know what you mean.

    Central Europe and Paris during the Weimar era was a time when people were curious about sex and felt the could talk about it openly. The open kinkiness of the Cabaret scene is well described in many movies and literature. It was in this setting that Viennese intellectuals discussed what everyone else was discussing and acting out. They were not divorced from the culture in which they lived. I'm afraid in modern residency setting, talking about sex like a 1935 Vienna psychoanalyst or even a 1960 St. Louis ob/gyn such as Masters might generate a harassment suit.