Erotophobia in a Young Female with Pituitary Microadenoma: A Case Report

Abstract

Erotophobia, or marked and excessive fear of sexual intimacy, associated with avoidance, or endurance with intense fear or anxiety, affects the sexual well-being of couples, often leading to unconsummated marriages. We studied the case of a 24-year-old Indian woman who had presented with fear and avoidance of sexual intimacy for the last three years, since marriage. She demonstrated significant intrapsychic conflict between a desire for motherhood and aversion to and fear of injury by sexual intercourse. She was also investigated for delayed menstrual cycles, reduced vaginal secretions, and galactorrhoea, and found to have hyperprolactinemia and pituitary microadenoma. She improved significantly with sertraline, cabergoline, and systematic desensitization, and went on to conceive spontaneously. This case series demonstrated the good prognosis with a thorough investigation and treatment, and highlights the importance of raising awareness and addressing shame and stigma, so as to ensure that affected couples receive the care that they need.

Introduction

As per International Classification of Diseases for Mortality and Morbidity Statistics, 11th Revision (ICD-11), specific phobia is characterized by marked and excessive fear or anxiety lasting for several months consistently occurring upon exposure or anticipation of exposure to one or more specific objects or situations that are out of proportion to actual danger, wherein the phobic objects or situations are avoided or else endured with intense fear or anxiety, leading to significant distress or dysfunction. ¹ When the phobic object is sexual intimacy, it is known as erotophobia, and when it is specifically the penetrative sexual intercourse which is perceived as the phobic object, the term used is genophobia or coitophobia. ²

This case report studies the case of a young woman who had presented to the psychiatry Outpatient Department (OPD) along with her husband with complaints of fear of sexual intercourse, along with avoidance of the same for the last three years, since marriage.

Case Report

A 24-year-old Indian woman, from lower socio-economic strata, married since two years to her first cousin (third degree consanguineous marriage), with no past or family history of psychiatric illness, and no history of sexual abuse, gender dysphoria or interpersonal conflicts, presented with a two-year history of low sexual desire, and persistent fear of sexual intimacy, which she noticed from her wedding day, during the first sexual encounter of her life. She would have restlessness, palpitations, cold sweats, tremors, and a sense of impending doom whenever her husband initiated physical intimacy, with conscious avoidance of reminders of sexual intimacy and constant anticipatory anxiety. Repeated attempts by her husband to initiate genital touching intensified her fear, particularly her apprehension of physical injury. With increasing societal pressure to conceive, she experienced guilt and self-doubt, desiring motherhood but averse to the requisite intimacy. She also reported irregular (delayed) menstrual cycles, reduced vaginal secretions, and galactorrhoea.

Mental status examination revealed a fidgety lady with anxious affect, irrational and excessive fear of sexual intimacy, and anticipatory anxiety, with decreased libido.

In view of marked and disproportionate fear and anxiety about a specific situation (sexual intercourse), and active avoidance, persisting for >6 months, causing significant distress, and dysfunction, the provisional diagnosis was specific phobia, with the differential diagnosis of female sexual interest/arousal disorder.

Detailed investigations, including hormonal assays, revealed hyperprolactinemia (56.2 ng/mL), and magnetic resonance imaging (MRI) of the brain revealed a pituitary microadenoma. Figure 1 shows the MRI Brain of the patient, with T1-weighted image (WI) and T2-WI sagittal (a) and coronal (b) sections showing a 6 mm-sized lesion in the anterior lobe of the right half of the pituitary gland (yellow arrow), which is hypointense on T1 and hyperintense on T2-WI.

Figure 1.

T1WI and T2WI Sagittal (a) and Coronal (b) Sections Showing a 6 mm-sized Lesion in Anterior Lobe of Right Half of Pituitary Gland (Yellow Arrow) Which is Hypointense on T1 and Hyperintense on T2 Weighted Images.

She was started on sertraline 50 mg/day, and systematic desensitization, exposing her to a hierarchy of stimuli, starting from clip-arts showing sexual intercourse, progressing to human pictures, videos, non-genital intimacy with husband, non-penetrative sexual act, and finally, to penetrative sexual intercourse, along with relaxation training using Jacobson’s progressive muscle relaxation. She was also started on cabergoline 0.5 mg weekly by the endocrinologist, and serum prolactin improved within a month (20 ng/mL), with consequent improvement in libido.

She improved significantly over the next 6–7 months and achieved remission. She is now able to have sexual intercourse and has also delivered her first child, a healthy male baby, now six months old.

This case was managed through a multidisciplinary approach, and although her reduced sexual desire was owing to a pituitary microadenoma, she also clearly benefited from psychopharmacological and psychotherapeutic management targeting her fear response.

Discussion

The study of the above case highlighted the multifactorial causation of erotophobia, leading to an unconsummated marriage in a young woman from India. Previous literature also reports that unconsummated marriage is a common problem in South Asia, occurring due to various factors, including but not limited to a lack of awareness, social taboos, medical illnesses, vaginismus, and fear of sexual intercourse. ³ Similar to our patient, who first reported to a psychiatrist after two years of marriage, it has been studied that most couples have a significant delay before seeking medical help. There are various reasons for the same, including social taboos and stigma, feelings of shame, not recognizing it as a medical problem, and also excessive fear of talking about it; therefore, the majority of couples facing a similar problem go unreported. ³ Pituitary disorders are also known to affect sexual desire and well-being, and the serendipitous diagnosis of a pituitary microadenoma in our patient helped us to delineate a significant causative factor for her symptoms. ⁴

Our patient improved significantly with both pharmacological and non-pharmacological measures, especially focusing on cognitive behavioral approaches, specifically systematic desensitization. This is also similar to previous literature on the topic. ³

Conclusion

Erotophobia, or the fear of sexual intimacy, is a significant and common problem, although it is largely underreported. Various factors contribute to it, and it affects the sexual well-being of couples, often leading to unconsummated marriages. This case report demonstrated the good prognosis with thorough investigation and both pharmacological and non-pharmacological measures, similar to previously published literature, highlighting the need to raise awareness to dispel the stigma and shame associated with it, so that affected couples seek help to improve their sexual well-being.