November 23 2012

SEXUAL DISORDERS
Dr. Rodriguez

Outline  Orgasm- peaking of sexual pleasure with release of sexual

A. Brain and Sexual Behavior
B. Physiological Sexual Response
C. The Sexual Dysfunctions
D. Signs of Sexual Addiction
E. Etiologic Considerations
F. Difficulties in Addressing Sexual Function
G. Management
Notes: Minimal notes from the book because the powerpoint was taken word per word
from the book as well.
THE BRAIN AND SEXUAL BEHAVIOR
 Through the Autonomic Nervous System (ANS)
o The limbic system is directly involved with
elements of sexual functioning.
o The parasympathetic (cholinergic) nervous
system activates the process of erection via
impulses that pass thru the pelvic splanchnic
nerves S2,S3,S4  smooth muscles of the penile
arteries dilate blood flows into the sinuses of
the corpora cavernosa blood flow from the
penis is inhibited erection.
o Parasympathetic stimulation increases blood
flow to clitoral tissue
o The clitoris has a nerve net that is
proportionately 3 times as large as that of the
penis
 Sexual Innervation of the male and female apparatus are
innervated by the parasympathetic nervous system 
Meaning it is INVOLUNTARY
 Hormones
o Fetal external genitalia are highly susceptible to
hormones.
o Testosterone- believed to be connected with
libido in men and women. In men, there is an
inverse correlation between stress &
testosterone levels.
o Other factors, like sleep, mood and lifestyle
influence circulating levels of hormones.
 Neurotransmitters
o Increase in dopamine  increased libido
o Serotonin produced in the upper pons &
midbrain is presumed to have an inhibitory
effect on sexual function.
o Those taking anti-deprresants like Zoloft. What is
their most notable side effects? Its erectile
dysfunction. That is why you should take Viagra
or Sidenafil too
THE SEXUAL RESPONSE CYCLE
 Desire – the presence of sexual fantasies and the desire
to have sexual activity
 Excitement- psychological & physical stimulation leading
to penile erection in the man, vaginal lubrication
in the woman & a host of other physiological changes
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tension & rhythmic contraction of the perineal muscles
& pelvic reproductive organs
 Resolution – detumescence
 If there is no desire the medications like Viagra
will not work because as we remember sex is
involuntary. That is why we should practice the
tongue and the finger.
SEXUAL DYSFUNCTIONS (DSM IV)
 Sexual Desire disorders
 Sexual Arousal disorders
 Orgasm disorders
 Sexual Pain disorders
 Sexual Dysfunction due to a GMC
 Substance-induced sexual dysfunction
 Sexual Dysfunction NOS
Hypoactive sexual dysfunction is more common in women. Erectile
dysfunction is the most common sexual dysfunction in men greater
than 40. Premature ejaculation is the most common sexual
dysfunction in men less than 40.
SEXUAL DESIRE DISORDER
1. Hypoactive Sexual Desire Disorder
 Deficiency or the absence of sexual fantasies or
desire for sexual activity
2. Sexual Aversion Disorder
 An aversion to and avoidance of genital sexual
contact with a sexual partner
* Specify if lifelong or acquired, generalized or situational, due to
psychological or combined factors.
Hypoactive Sexual Disorder
 More common sexual desire disorder
 Experienced by both men and women
 May be used to mask another sexual dysfunction
 Prevalence rates: 20% of the total population, more
common among women
 Lack of desire may be expressed by:
- decreased frequency of coitus
- perception of the partner as unattractive
- overt complaints of lack of desire
 Women exhibit far more variation in their psychological
reactions to their inability to respond to sexual
stimulation.
 For the man, erectile dysfunction is almost always a
psychological disaster.
 The responses of women to a comparable sexual inhibition
range from similar great distress to a causal acceptance of
their condition.
SEXUAL AROUSAL DISORDER
1. Female Sexual Arousal
 Persistent or recurrent ability to attain, or to
maintain until completion of the sexual activity,
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 an adequate lubrication swelling response of
sexual excitement
2. Male Erectile Disorder
 Persistent or recurrent ability to attain, or to
maintain until completion of the sexual activity,
an adequate erection
 The erectile difficulties in Male Erectile Disorder are
frequently associated with sexual anxiety, fear of
failure, concems about sexual perfomance, and a
decreased subjective sense of sexual excitement and
pleasure. Erectile dysfunction can disrupt existing
marital or sexual relationships and may be the ca use
of unconsummated marriages and infertility. This
disorder may be associated with Hypoactive Sexual
Desire Diso rder and Premature Ejaculation. individuals
with Mood Disord ers andSubstance-Related Disorders
often report problems with sexual arousal. (DSM IV)
* Specify if lifelong or acquired, generalized or situational, due to
psychological or combined factors.
ORGASMIC DISORDERS
1. Female Orgasmic Disorder
 Persistent or recurrent delay in, or absence of,
orgasm following a normal sexual excitement
phase.
 Women exhibit wide variability in the type or
intensity of stimulation that triggers orgasm. The
diagnosis of female orgasmic disorder should be
based on the clinician’s judgment that the
woman’s orgasmic capacity is less than would be
reasonable for her age, sexual experience & the
adequacy of sexual stimulation she receives.
2. Male Orgasmic Disorders
 Persistent or recurrent delay in, or absence of,
orgasm following a normal sexual excitement
phase during sexual activity that the clinician,
taking into account the person’s age, judges to
be adequate in focus, intensity & duration.
 Erection hardness scale by urologist. 1 – no
harndess, 2 – hardness but not enough for
penetration 3 – hardness able to penetrate but
cannot sustain. 4 – all the way.
* Specify if lifelong or acquired, generalized or situational, due to
psychological or combined factors
SEXUAL DYSFUNCTION AND SEXUAL DISORDER NOT
OTHERWISE SPECIFIED
* Sex Addiction – NOT YET in DSM but becoming more prevalent
like some people in show business. ;)
 Postcoital Dysphoria
 Couple Problems
 Unconsummated Marriage
 Body Image Problems
 Don Juanism
 Nymphomania
 Fantasies
 Persistent and Marked Distress about Sexual Orientation
 Postcoital Headache
 Orgasmic Anhedonia
 Masturbatory Pain
 Paraphilias (i.e., Frotteurism – rubbing or organ like in
crowded places, Fetishism – example is ampalaya or bitter
gourd.)
SIGNS OF SEXUAL ADDICTION
 Out of control behavior
 Severe adverse consequences (medical, legal,
interpersonal) due to sexual behavior
 Persistent pursuit of self-destructive or high-risk sexual
behavior
 Repeated attempts to limit or stop sexual behavior
 Sexual obsession & fantasy as a primary coping mechanism
 The need for increasing amounts of sexual activity
 Severe mood changes related to sexual activity
 Inordinate amount of time spent in obtaining sex, being
sexual or recovering from sexual activity
 Interference of sexual behavior in social, occupational, or
recreational activities
ETIOLOGIC CONSIDERATIONS
 Medical conditions like hypothyroidism, DM, primary
hyperprolactinemia
 Surgical procedures causing temporary dyspareunia
 Conditions involving organs of the reproductive system
that may cause dyspareunia, vaginismus
 Drugs/medications like antiHPN meds, CNS stimulants,
antidepressants
 Other sexual dysfunctions like sexual aversion disorder,
sexual arousal disorder, orgasmic disorder and sexual pain
disorders

SEXUAL PAIN DISORDERS PHARMACOLOGIC AGENTS IMPLICATED IN SEXUAL

1. Premature Ejaculation – persistent or recurrent ejaculation DYSFUNCTION
with minimal sexual stimulation before, on, or shortly after  Antipsychotic drugs
penetration & before the person wishes it.  Antidepressant drugs
2. Dyspareunia – recurrent or persistent genital pain  Lithium
associated with sexual intercourse in either male or  Psychostimulants
female.  Alpha Adrenergic & Beta Adrenergic receptor antagonists
3. Vaginismus – recurrent or persistent involuntary spasm of  Anticholinergics
the musculature of the outer third of the vagina that  Antihistamines
interferes with sexual intercourse  Antianxiety agents
4. Sexual Dysfunction and Sexual Disorder Not Otherwise  Alcohol
Specified  Opioids
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  Hallucinogens
 Cannabis
 Barbiturates & other CNS depressants
 Dopamine – direct relationship with libido. Increase
dopamine increase libido. Serotonin – inverse
relationship with libido. Increase serotonin decrease
libido. (This will be asked in the exam)
PSYCHOCOLOGICAL ETIOLOGIC CONSIDERATIONS
 Childhood sexual trauma
 Repeated painful experiences with coitus
 Unconscious connections between sex and overwhelming
feelings of shame and guilt
 Perceived psychological assault by the person’s partner
 Relationship difficulties
 Chronic stress, anxiety or depression
 Prolonged suppression of the sexual impulse
 Partner’s/Husband’s responses
CULTURAL ETIOLOGIC CONSIDERATIONS
 Women are not subject to the same sexual pressures to
perform as men are.
 In our society, the woman’s role in sexuality is to give man
pleasure and bear children.
 Most of these women are advised to accept or adjust to
their inorgastic state.
DIFFICULTIES IN ADDRESSING SEXUAL FUNCTION
 Lack of sexual education in medical school and residency
 Lack of FDA approved treatment options for sexual
dysfunction
 Discomfort with the topic
 Time constraints
 Patient’s embarrassment
 Consultation focused solely on pregnancy
MANAGEMENT
 The presence of desire depends on:
1. Biological drive
2. Adequate self-esteem
3. Previous good experiences with sex
4. Availability of an appropriate partner
5. A good relationship in non-sexual areas with one’s
partner
 General medical work-up to rule out a medical cause
 Management of medical causes
- Pharmacotherapy
* Sildenafil in the treatment of Erectile Dysfunction- a PDE-
5 inhibitoractivates guanylate cyclaseinc. cyclic
guanosine monophosphate(cGMP)smooth muscle
relaxation in the corpus cavernosumblood inflow during
sexual stimulation
- hormone therapy (androgens for ED, antiandrogens for
sex addiction)
- penile injections, prosthesis
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- surgery
 Individual psychotherapy, couple therapy
 Sex therapy
SEX THERAPY
 Dual sex therapy by Masters and Johnson
 Sensate focus exercises - sexual activity is limited to gentle
touching & caressing each other’s body
 Genital stimulation – light, teasing genital play
 Non-demand coitus – the woman’s awareness of
pleasurable vaginal sensations increases considerably
when coital thrusting is under her control, with the sole
objective of augmenting her sensory awareness
 Behavior therapy
Results of Sex Therapy
1. Because the woman is not pressured to produce a
response, she is not apt to mobilize her defenses &
anxiety.
2. The stimulation is provided primarily for the woman’s
erotic pleasure.
3. The couple becomes more perceptive & sensitive to each
other’s sexual needs & reactions.
4. The defenses initially held on to begin to dissolve in the
relaxed sexual ambience & open authentic
communication.
RESULTS OF TREATMENT
 Depends on the cause
 The more severe the psychopathology associated with a
problem of long duration, the more adverse the outcome
is likely to be.
 Better outcomes are associated with:
- couples who regularly practice assigned exercises
- flexibility of attitude
- younger couples tend to complete the therapy
KEY POINTS
 Psychosocial factors should be part of the evaluation and
management of sexual disorders.
 When appropriate, management of psychosocial factors
may preclude the use of expensive and unnecessary
treatments for sexual disorders.
M V & J were so tired of the drama that was happening between them and
the mean girls. J realized that they don't have to compromise anymore and
should just do what makes them happy. Since then every time the mean girls
came they would just ignore them which pissed the mean girls more. Out of
nowhere a butterfly came to V's hair which made them realized that they
should just be themselves and do things that made them happy. What story
would like them to be happy? None! So the mean girls thought of a plan that
would shatter MJV's barrier. Stay Tuned!
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