Sexual disorders

SEXUAL DYSFUNCTIONS 2 Hours
Sexual dysfunctions are disorders characterized by a disturbance in a person’s ability to respond sexually or to experience sexual pleasure.
There are Seven major categories of sexual dysfunctions:
(1) sexual desire disorders,
(2) sexual arousal disorders,
(3) orgasmic disorders,
(4) sexual pain disorders,
(5) sexual dysfunction due to a general medical condition,
(6) substance-induced sexual dysfunction, and
(7) sexual dysfunction not otherwise specified.
Characterize by:-
1. The subject is unable to participate in a sexual relationship as he or she would wish.
2. The dysfunction occurs frequently, but may be absent on some occasions.
3. The dysfunction has been present for at least 6 months.
4. The dysfunction is not entirely attributable to any of the other mental and behavioral disorders, physical disorders (such as endocrine disorder), or drug treatment.


PHYSIOLOGICAL RESPONSES
Phase I: Desire
Phase I: is distinct from any identified physiology and It is characterized by sexual fantasies and the desire to have sexual activity.
Dysfunctions: e.g. Hypoactive sexual desire; substance-induced sexual dysfunction with impaired desire

Phase II: Excitement
Phase II is brought on by psychological stimulation (fantasy or the presence of a love object), physiological stimulation (stroking or kissing), or a combination of the two. It consists of a subjective sense of pleasure. The excitement phase is characterized by penile erection in the man and vaginal lubrication in the woman. The nipples of both sexes become erect, although nipple erection is more common in women than in men.
The woman s clitoris becomes hard, and her labia minora become thicker as a result of venous engorgement. Initial excitement may last several minutes to several hours. With continued stimulation, the man s testes increase in size 50 percent and elevate. The woman s vaginal barrel shows a characteristic constriction along the outer third known as the orgasmic platform. The clitoris elevates and retracts behind the symphysis pubis; hence it is not easily accessible. However, stimulation of the area causes traction on the labia minora and the prepuce, and there is intrapreputial movement of the clitoral shaft.
Breast size in the woman increases 25 percent. Continued engorgement of the penis and vagina produces specific color changes, particularly in the labia minora, which become bright or deep red. Voluntary contractions of large muscle groups occur, rate of heartbeat and respiration increases, and blood pressure rises. Heightened excitement lasts 30 seconds to several minutes.

Dysfunctions:
Female sexual arousal disorder; male erectile disorder (may also occur in stages 3 and 4); male erectile disorder due to a general medical condition; dyspareunia due to a general medical condition (male or female); substance-induced sexual dysfunction with impaired arousal

Phase III: Orgasm
Phase III consists of peaking sexual pleasure, with release of sexual tension and rhythmic contraction of the perineal muscles and pelvic reproductive organs. A subjective sense of ejaculatory inevitability triggers the man s orgasm.
Forceful emission of semen follows. The male orgasm is also associated with four to five rhythmic spasms of the prostate, seminal vesicles, vas, and urethra. In the woman orgasm is characterized by 3 to 15 involuntary contractions of the lower third of the vagina and by strong, sustained contractions of the uterus, flowing from the fundus downward to the cervix. Both men and women have involuntary contractions of the internal and external sphincter. Those and the other contractions during orgasm occur at 0.8-second intervals. Other manifestations include voluntary and involuntary movements of the large muscle groups, including facial grimacing and carpopedal spasm.
Blood pressure rises 20 to 40 mm (both systolic and diastolic), and the heart rate increases up to 160 beats a minute. Orgasm lasts from 3 to 25 seconds and is associated with a slight clouding of consciousness.
Dysfunctions:
Female orgasmic disorder; male orgasmic disorder; premature ejaculation; other sexual dysfunction due to a general medical condition (male or female); substance-induced sexual dysfunction with impaired orgasm


Phase IV: Resolution
Resolution consists of the disgorgement of blood from the genitalia (detumescence), which brings the body back to its resting state. If orgasm occurs, resolution is rapid; if it does not occur, resolution may take 2 to 6 hours and be associated with irritability and discomfort. Resolution through orgasm is characterized by a subjective sense of well-being, general relaxation, and muscular relaxation. After orgasm men have a refractory period that may last from several minutes to many hours; in that period they cannot be stimulated to further orgasm. The refractory period does not exist in women, who are capable of multiple and successive orgasms.



Dysfunctions:
Postcoital dysphoria; postcoital headache

Sexual Dysfunction Not Correlated With Phases of the Sexual Response Cycle: Vaginismus (female) , Dyspareunia (female and male)
The most common sexual problems are:
1. erectile dysfunction (males)
2. premature ejaculation (males)
3. vaginismus (females)
4. low sexual desire (females, males)
5. inhibited female orgasm
Characteristics of the DSM-IV Sexual Dysfunctions
Disorder Characteristics
Hypoactive sexual desire
disorder Decreased interest in sexual activity
Sexual aversion disorder Aversion to and avoidance of sexual activity
Female sexual arousal
disorder Inability to maintain vaginal lubrication until the sex act is completed, despite adequate physical stimulation (reported in as many as
20% of women)
Male erectile disorder
(commonly
called "impotence") Lifelong or primary (rare): has never had an erection sufficient for penetration Acquired or secondary (the most common male sexual disorder): is currently unable to maintain erections despite normal erections in the past Situational (common): has difficulty maintaining erections in some sexual situations, but not in others


Orgasmic disorder (male and
female) Lifelong: has never had an orgasm Acquired: is currently unable to achieve orgasm despite adequate genital stimulation and normal orgasms in the past Reported more often in women than in men
Premature ejaculation Ejaculation before the man would like it to occur Plateau phase of the sexual response cycle is short or absent Is usually accompanied by anxiety Is the second most common male sexual disorder
Vaginismus Painful spasms occur in the outer third of the vagina, which make intercourse or pelvic examination difficult
Dyspareunia Persistent pain occurs in association with sexual intercourse without pelvic pathology (functional dyspareunia) Can also be caused by pelvic pathology, e.g., pelvic inflammatory disease (PID) caused by chlamydiosis (most common) or gonorrhea (most serious)
Occurs much more commonly in women; can occur in men


Assessment of a psychosexual problem:
+define the problem
? nature ? onset ? severity ? complications

+ Assess sexual history:
? puberty ? fantasy ? orientation ? practice ? drive ? education ? expectations ? sexual traumas (e.g. rape)
+ Sex atmosphere (privacy, foreplay…)
+ Psychiatric disorders: ? Depression ? Anxiety
+ Physical diseases e.g. diabetes mellitus, hypertension…

ERECTILE DISORDER (IMPOTENCE)
• Inability to attain or maintain enough erection until completion of satisfactory coitus.
• Causes include:
• Physical diseases e.g. diabetes mellitus, arterioscleresis, drugs, alcohol.
• Psychological: anxiety, depression.
* Presence of morning erection suggests a psychological cause particularly in an anxious person who is sensitive to issues related to sex.
• Complications: depression, anxiety, unconsummated marriage and divorce.

Management includes:
? Identifying and treating any possible underlying physical or psychiatric problems.
? Psychological treatment : Education about normal sexual phases and the importance of privacy and foreplay.
• Improving the couple communication (increasing understanding of the wishes and feelings of the other partner).
??Behaviour techniques: gradually reducing performance anxiety and increasing sensual sexual feelings
? Physical treatment include intacavernosal injection of prostaglandin El (smooth muscle relaxant), sildenafil (viagra) and vacuum devices.
Behavioral treatment techniques
1-In sensate-focus exercises (used to treat sexual desire, arousal, and orgasmic disorders), the individual s awareness of touch, sight, smell, and sound stimuli are increased during sexual activity, and psychological pressure to achieve an erection or orgasm is decreased.
2-In the squeeze technique, which is used to treat premature e jaculation, the man is taught to identify the sensation that occurs just before the emission of semen. At this moment, the man asks his partner to exert pressure on the
coronal ridge of the glans on both sides of the penis until the erection subsides, thereby delaying ejaculation.
3-Relaxation techniques, hypnosis, and systematic desensitization used to reduce anxiety associated with sexual performance.
4-Masturbation may be recommended to help the person learn what stimuli are most effective for achieving arousal and orgasm.
Medical and surgical treatment
1-Because they delay orgasm, SSRIs a. (e.g., fluoxetine) are used to treat premature ejaculation.
2-Systemic administration of opioid antagonists (e.g., naltrexone) and vasodilators (e.g., yohimbine) have been used to treat erectile disorder.
3-In erectile disorder, sildenafil citrate (Viagra) and related agents work by blocking an enzyme (phosphodiesterase-5) that destroys cyclic guanosine monophosphate (cGMP), a vasodilator secreted in the penis with sexual stimulation. Thus, degradation of cGMP is slowed and the erection persists. Side effects include blue vision, and it is contraindicated in men who take nitrates. Newer PDE5 inhibitors with greater potency and selectivity than sildenafil
include vardenafil (Levitra, Nuviva) and tadalafil (Cialis).
3-Intracorporeal injection of vasodilators (e.g., papaverine, phentolamine) or implantation of prosthetic devices are also used to treat erectile dysfunction.
4-Apomorphine hydrochloride (Uprima) increases sexual interest and erectile function by increasing dopamine availability in the brain. It is dissolved sublingually and its side effects include postural hypotension and syncope
(fainting).

??PREMATURE EJACULATION:
Ejaculation with minimal sexual stimulation (before, upon, or shortly after penetration) and before the person wishes it so that woman gains no pleasure. It is common among young newly married men. It may improve with increasing sexual experience.

Treatment includes:
• Sex education
• Anxiety reduction (relaxation training, anxiolytics)
• Squeeze or stop-start technique (the woman interrupts foreplay whenever the man feels highly aroused, in order to prolong the period of arousal before reaching orgasm).
• Some psychotropic drugs delay ejaculation (e.g. clomipramine, Flouxetine, thioridazine) can be given few hours before sex.

??VAGINISMUS:
An involuntary painful muscle spasm of the vaginal muscles (outer third) that interferes with penile insertion. Thigh muscles may also contract. The condition may be made worse by an inexperienced harsh partner. Some cases had past history of sexual abuse. Anxious sensitive women are at higher risk. Both situational and acquired dyspareunia may reflect a woman’s conscious or unconscious motivation to avoid sex with a particular partner;

Complications include: ? Anxiety ? Depression ? Marital discord, unconsummated marriage and divorce.
Treatment:
• Education and explanation: exploration of the developmental and interpersonal meanings of the need for the symptom.
• Graded behavioral approach (woman is encouraged to gradually insert her finger into vagina= pairing relaxation techniques with progressively larger vaginal dilators) wait until anxiety disappears doing this repeatedly (with increasingly larger probes) facilitates the process of muscle relaxation and vaginal lubrication.
• Additional lubrication may be required to facilitate penile penetration.
• Anxiety reduction (relaxation training, anxiolytics).

Paraphilias:
consisting of recurrent, intensely sexually arousing fantasies, sexual urges, or sexual behaviors that involve either nonhuman objects, the suffering of the self or partner, children, or non consenting persons.

ICD-10 Diagnostic Criteria for Disorders of Sexual Preference
G1. The individual experiences recurrent intense sexual urges and fantasies involving unusual objects or activities.
G2. The individual either acts on the urges or is markedly distressed by them.
G3. The preference has been present for at least 6 months.
Fetishism
A. The general criteria for disorders of sexual preference must be met.
B. The fetish (some nonliving object) is the most important source of sexual stimulation or is essential for satisfactory sexual response.

Fetishistic transvestism
A. The general criteria for disorders of sexual preference must be met.
B. The individual wears articles of clothing of the opposite sex in order to create the appearance and feeling of being a member of the opposite sex.
C. The cross-dressing is closely associated with sexual arousal. Once orgasm occurs and sexual arousal declines, there is a strong desire to remove the clothing.

Exhibitionism
A. The general criteria for disorders of sexual preference must be met.
B. There is either a recurrent or a persistent tendency to expose the genitalia to unsuspecting strangers (usually of the opposite sex), which is almost invariably associated with sexual arousal and masturbation.
C. There is no intention or invitation to have sexual intercourse with the "witness(es)."

Voyeurism
A. The general criteria for disorders of sexual preference must be met.
B. There is either a recurrent or a persistent tendency to look at people engaging in sexual or intimate behavior such as undressing, which is associated with sexual excitement and masturbation.
C. There is no intention to reveal one s presence.
D. There is no intention of sexual involvement with the person(s) observed.

Pedophilia
A. The general criteria for disorders of sexual preference must be met.
B. There is a persistent or predominant preference for sexual activity with a prepubescent child or children.
C. The individual is at least 16 years old and at least 5 years older than the child or children in criterion B.

Sadomasochism
A. The general criteria for disorders of sexual preference must be met.
B. There is preference for sexual activity, as recipient (masochism) or provider (sadism), or both, which involves at least one of the following:
(1) pain;
(2) humiliation;
(3) bondage.
C. The sadomasochistic activity is the most important source of stimulation or is necessary for sexual gratification.
Multiple disorders of sexual preference
The likelihood of more than one abnormal sexual preference occurring in one individual is greater than would be expected by chance. the different types of preference and their relative importance to the individual, should be listed. The most common combination is fetishism, transvestism, and sadomasochism.
Other disorders of sexual preference

A variety of other patterns of sexual preference and activity may occur, each being relatively uncommon. These include such activities as making obscene telephone calls to unknown persons (Scatologicia), rubbing up against people for sexual stimulation in crowded public places (Frotteurism), sexual activity with animals(zoophilia), use of strangulation or anoxia for intensifying sexual excitement, and a preference for partners with some particular anatomical abnormality such as an amputated limb.

Erotic practices are too diverse and many too rare or idiosyncratic to justify a separate term for each. Swallowing urine, smearing feces, or piercing foreskin or nipples may be part of the behavioral repertoire in sadomasochism. Masturbatory rituals of various kinds are common, but the more extreme practices, such as the insertion of objects into the rectum or penile urethra, or partial self-strangulation, Practicing sex with cadaver (Necrophilia)

DSM-IV Diagnostic Criteria for Gender Identity Disorder
A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).
In children, the disturbance is manifested by four (or more) of the following:
(1) repeatedly stated desire to be, or insistence that he or she is, the other sex
(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
(4) intense desire to participate in the stereotypical games and pastimes of the other sex
(5) strong preference for playmates of the other sex.
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Gender Identity, Gender Role, and Sexual Orientation
Term Definition Presumed Etiology Comments
Gender identity Sense of self as being male or female

Differential exposure to prenatal sex hormones May or may not agree
with physiological sex or gender role (i.e., gender identity disorder)
Gender role



Expression of one s
gender identity in society Societal pressure to conform to sexual norms May or may not
agree with gender identity or physiological sex
Sexual orientation Persistent and
unchanging
preference for
people of the same sex (homosexual) or
the opposite sex
(heterosexual)
for love and sexual
expression Differential
exposure to
prenatal sex
hormones
Genetic
influences True bisexuality is
uncommon; most people have a sexual preference
Homosexuality is
considered a normal
variant of sexual expression


ILLNESS AND SEXUALITY
A. Heart disease and myocardial infarction (MI)
1-Men who have a history of MI often have erectile dysfunction. Both men and women who have a history of MI may have decreased libido because of side effects of cardiac medications and fear that sexual activity will cause another heart attack.
2- Generally, if exercise that raises the heart rate to 110–130 bpm (e.g., exertion equal to climbing two flights of stairs) can be tolerated without severe shortness of breath or chest pain, sexual activity can be resumed after a heart attack.
3- Sexual positions that produce the least exertion in the patient (e.g., the partner in the superior position) are the safest after MI.
B. Diabetes
1- One quarter to one half of diabetic men (more commonly older patients) have erectile dysfunction. Orgasm and ejaculation are less likely to be affected.
2- The major causes of erectile dysfunction in men with diabetes are vascular changes and diabetic neuropathy caused by damage to blood vessels and nerve tissue in the penis as a result of hyperglycemia.
a- Erectile problems generally occur several years after diabetes is diagnosed but may be the first symptom of the disease.
b- Poor metabolic control of diabetes is related to increased incidence of sexual problems.
c- Sildenafil citrate and related agents often are effective in diabetes-related erectile disorders.
d- Although physiologic causes are most important, psychological factors also may influence erectile problems associated with diabetes.