SEXUAL DISORDERS

By: DR AINI SIMON

SEXUAL DEVELOPMNET
Prenatal physical sexual development  Differentiation of the gonads is dependent on the presence or absence of the Y chromosome, which contains the testis-determining factor gene.  The androgenic secretions of the testes direct the differentiation of male internal and external genitalia. a. In the absence of androgens during prenatal life, internal and external genitalia are female. b. In androgen insensitivity syndrome (formerly testicular feminization), despite an XY genotype and testes that secrete androgen, a genetic defect prevents the body cells from responding to androgen, resulting in a female phenotype. At puberty, the descending testes may appear as labial or inguinal masses. c. In the presence of excessive adrenal androgen secretion prenatally (congenital viriliz-ing adrenal hyperplasia; formerly adrenogenital syndrome), the genitalia of a genetic female are masculinized and the child may be identified initially as male.

Hormones and sexual behavior 
Generally substance that increase dopamine

levels in brain INCREASE desire and subtance that augment serotonin DECREASE desire.  Testosterone increase libido in both.  Progesterone mildly decrease desire as do excessive prolactin and cortisol.  Oxytocin is involve in pleasurable sensations during sex.

Biology of Sexuality in Adults
In adults, alterations in circulating levels of gonadal hormones (estrogen, progesterone, and testosterone) can affect sexual interest and expression. A. Hormones and behavior in women  Because estrogen is only minimally involved in libido, menopause (i.e., cessation of ovar-ian estrogen production) and aging do not reduce sex drive if a woman's general health is good.  Testosterone is secreted by the adrenal glands (as well as the ovaries and testes) through-out adult life and is believed to play an important role in sex drive in both men and women. B. Hormones and behavior in men. - Testosterone levels in men generally are higher than necessary to maintain normal sexual functioning; low testosterone levels are less likely than relationship problems, age, or unidentified illness to cause sexual dysfunction.  Psychological and physical stress may decrease testosterone levels.  Medical treatment with estrogens, progesterone, or antiandrogens (e.g., to treat prostate cancer) can decrease testosterone availability via hypothalamic feedback mechanisms, resulting in decreased sexual interest and behavior.

Gender and sexuality 
Men
Think more about sex Want more sex Want more and have more partners Have more sexual dysfuction as they age 

Women
Desire for sex more often linked to relationship status and social norms 

At all ages, women more likely to report

sexual dysfunction as compared to men.

The Sexual Response Cycle  1. Masters and Johnson devised a four-stage model for sexual response in both men and women. Sexual dysfunctions involve difficulty with one or more aspects of the sexual response cycle and can overlapped. including the Desire-sexual fantasies and the desire to have sexual activity Excitement-sense of pleasure Orgasm-peaking of sexual pleasure Resolution-back to resting state  2. .

Male Sexual Anatomy .

Female Sexual Anatomy .

.

Sexual Gender And Identity Disorder Sexual Dysfunction Sexual Dysfunction 2 GMC/Substance abuse Sexual Dysfunction NOS Paraphilias Gender Identity Disorder Sexual Disorder NOS Desire Arousal Orgasm Pain Fethishim pedophilia Sadism Voyeurism .

Diagnosis  Must cause marked distress or interpersonal difficulty to person life  Specifiers Lifelong(primary) vs acquired (secondary) Global vs situational Gradual vs sudden  Differentiate from secondary to a medical or psychiatric condition Physical disease Substance abuse Medication .

g. Psychological causes include current relationship problems. performance pressure).  b. and hormonal or neurotransmitter alterations. depression.  .  a. side effects of medication [e. 2. selective serotonin reuptake inhibitors (SSRIs) can cause delayed orgasm]. the presence of morning erections.g. alcohol use can cause erectile dysfunction). pelvic adhesions can cause dyspareunia). psychological. or erections during rapid eye movement (REM) sleep suggests a psychological rather than a physical cause.SEXUAL DYSFUNCTIONS Sexual dysfunction can result from biological. more commonly.g. Biological causes include an unidentified general medical condition (e. they occur after an interval when function has been normal (secondary sexual dysfunctions). stress. Dysfunctions may always have Been present (primary sexual dysfunctions)... or interpersonal causes.. substance abuse (e. or.. or from a combination of causes. In men with erectile disorder. diabetes can cause erectile dysfunction. and anxiety (e. guilt.g. erections during masturbation.

 The orgasmic disorders are male orgasmic disorder. DSM-IV-TR .  The sexual arousal disorders are female sexual arousal disorder MALE ERECTILE DISORDER (disorders of the excitement and plateau phases).  The sexual pain disorders are dyspareunia vaginismus (not due to a general medical condition). PREMATURE EJACULATION (disorders of the orgasm phase).CLASSIFICATIONS OF SEXUAL DYSFUNCTION By PHASE OF SEXUAL CYCLE  The sexual desire disorders are hypoactive sexual desire disorder sexual aversion disorder (disorders of the excitement phase). female orgasmic disorder.

panic avoidance .Sexual Desire Disorders  Hypoactive sexual desire disorder Deficient or absent sexual fantasies and urges Low sex drive  Sexual aversion disorder Individual actively avoids nearly all genital contacts with another person sexual phobia Classically conditioned response ‚ assault + sex = fear.

Sexual Arousal Disorder  Female Consistently inadequate vaginal lubrication for comfortable completion of intercourse  Male Most common is Erectile Dysfunction Persistent failure to attain or maintain an erection through completion of the sexual activity Theory: pressure on pudendal artery in the glands penis can lead to ED Dettori. 2004: study 463 cyclists 320km race ‚ 4.2% had ED 1 week later ‚ 1.8% had ED 1 month later .

‚ It is associated with low self confidence in men ‚ Women report fear that the partner is unfaithful .. >>> YES..Orgasmic Disorder  Female Orgasmic Disorder Absence of orgasm after sexual excitement  Male Orgasmic Disorder Persistent difficulty ejaculating Is this really a problem?..

6min England. .6min  Hypothesis Low levels of serotonin >> less activation at 5-HT receptor>>lowers ejaculatory set point. France.7min US-13.Premature Ejaculation Ejaculation that occurs too quickly 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 The most common male sexual disorder  How early? In large studies shows that time take to ejaculate 7-14min Germany. Italy-9.

Sexual Pain Disorder  Dyspareunia Persistent or recurrent pain during intercourse Diagnosable in both men and women In woman most common is vulva vestibulitis syndrome (VVS) in 15-21%  Vaginismus Involuntary spasm of the outer third of the vagina Prevent penetration .

intromission. accompanied by pain and tenderness ‚ Commonly associated with antipsychotic use .persistent abnormal erection of the penis. thrusting or ejaculation Likely due to PROSTATITIS Allergic to spermicidal creams Poor hygiene in uncircumcised men Priapism. Sexual pain in men Can take place during erection.

and so on)  Benign diseases (e. hypoestrogenism.g. dyspareunia/chronic pain associated with endometriosis) Predisposing factors contributing to sexual dysfunction Graziottin et al (2006) . diabetes)  Recurrent vulvovaginitis and/or cystitis  Pelvic floor disorders: lifelong or acquired  Drug treatments affecting biovailability of sex steroids or neurotransmitter levels  Chronic diseases (cardiovascular. adrenal dysfunction.g. neurologic or psychiatric diseases. thyroid dysfunction. hyperprolactinemia. endometriosis) predisposing to iatrogenic menopause and dyspareunia  Persistent residual conditions (e.Biologic  Endocrine disorders (hypoandrogenism.

depression. or abuse  Body image issues/concerns  Affective disorders (dysthymia.Psychosexual  Inadequate/delayed psychosexual development  Borderline personality traits  Previous negative sexual experiences: sexual coercion. violence. mania) and anxiety disorders  Inadequate coping strategies  Inadequate sexual education Graziottin et al (2006) .

Contextual  Ethnic/religious/cultural messages. and  constraints regarding sexuality  Social ambivalence towards sexual activity. when separated from reproduction or marriage  Negative social attitudes towards female contraception  Low socioeconomic status/reduced access to medical care and facilities  Support network Graziottin et al (2006) . expectations.

a middle-aged married male patient may be having an extramarital homosexual relationship).").g. TREATMENT . "I have a problem with sex.. Treatment of sexual problems may be behavioral. The physician must understand the patient's sexual problem before proceeding with treatment (e.  3. medical or surgical. The physician should not assume anything about a patient's sexuality (e.g.   2.. clarify what a patient means when he says.TREATMENT FOR SEXUAL DYSFUNCTION  1.

Psychological treatment : Sensate Focus  Developed by Masters and Johnson Stage 1 touch body (no genitals or breast) with goal of increasing awareness Limited touching Ignore arousal  Stage 2 Touching all over receiver guides hand of toucher .

Stage 3 ‚ Mutual touching that feels natural ‚ Begin to shift attention away from own body onto partner s Stage 4 ‚ Increase genital touching with goal of arousal ‚ Proceed to intercourse when ready  Therapy 2-3X/week  Failure rates very low (maximum 20%)  Relapse rates 5% .

Cognitive Behavioral Therapy  Combination of cognitive therapy (challenging maladaptive sexual believes and behavioral therapy (exercise) and education .

Couple Therapy  Communication training  Marital Therapy  Problem solving  Assertiveness training  Examining the system .how does the dysfunction keep the relationship balanced? .

Physical Treatment  Dilators for vaginismus  Vacuum Erection Devices Tube placed over flaccid penis Automatic and manual pump draws blood into penis Rubber band placed over base of erect penis to maintain erection .

 Stop-start technique Partner manually stimulates until erection Either stop stimulation or squeeze the prepuce (muscle under head of penis) Extends foreplay and teaches ejaculatory control .

 Intracarvenosal injections for ED Prostaglandin E1 (Alprostadil)-no sexual stimulation is needed to relax muscle  Transurethral therapy .

nasal congestion.Medications for ED  Sildenafil (Viagra) 4H half life 1H before planned sexual activity S/E: headache. flushing. visual disturbances  Vardenafil (Levitra) 1H before planned sexual activity 4-6H half life  Tadalafil (Cialis) 30 min before sexual activity 17H half life Less side effects . dyspepsia.

 Does not CREATE erections. only maintains vasocongestion Sexual stimulation Nitric oxide activates Erection Guanylyl cyclase produce Promotes smooth muscle relaxation cGMP PDE5 .

Surgery  Vestibulectomy Close to 100% cure rates Excision of the hymen and sensitive areas of the vestibules .

GENDER IDENTITY DISORDER  Formerly known as transsexualism  Individual feels that they are of the opposite sex despite normal genitals and these feelings usually present since childhood  May seek out surgery to alter body  Individuals with GID may be sexually attracted to same or opposite sex individuals .

ETIOLOGY OF GENDER DISORDER  Genetic factor Twin studies indicate some symptoms moderately heritable  Neurobiological Factors Exposure to high level of sex hormone in utero  Social and psychological factors Reinforcement of cross gender behaviour .

TREATMENT  Sex reassignment surgery Alter person s sexual anatomy to match internal identity  Behavioral treatment to alter gender identity Shaping of more masculine behaviours May only be effective for individuals who wants treatment for GID .

PARAPHILIAS .

 2. To fit DSM-IV-TR criteria. the behavior must continue over a period of at least 6 months. Pharmacologic treatment includes antiandrogens and female sex hormones for para-philias that are characterized by hypersexuality. .  1. and cause impairment in occupational or social functioning.Paraphilias involve the preferential use of unusual objects of sexual desire or engagement in unusual sexual activity. Paraphilias occur almost exclusively in men.

stockings. rubber garments Occurs most offen in men  Attraction to object irresistable and involuntary .Fetishism  Reliance on an inanimate object for sexual arousal Eg: shoes. underwear.

TRANSVESTIC FETISHISM  Transvestism Recurrent intense sexual arousal from cross dressing No desire to be of the opposite sex .

fantasies or behaviours involving sexual contact with prepubescent child  Victims usually known to pedophile  Mostly does not involve violence other than the sexual activity .PEDOPHILIA  Sexually arousing urges.

urges or behaviors involving observing other who are unclothed or engaging in sexual activity Almost always men Seldom result in physical contact with victim Victim unaware that they are being watched .Voyeurism  Sexually arousing fantasies.

EXHIBITIONISM  Intense desire to obtain sexual gratification by exposing one s genitals to unwilling stranger Seldom results in physical contact with victim Usually involve desire to shock or alarm victim .

Frotteurism  Sexually oriented touching of a nonconsenting person Rubs his genitals against a woman body of fondles her breast or genitals Usually occur in crowded subway or other public place .

SEXUAL SADISM AND MASOCHISM  Sadism Intense and recurrent desire to obtain or increase sexual gratification by inflicting pain or psychological suffering on another person  Masochism Intense and recurrent desire to obtain or increase sexual gratification through receiving pain or humiliation .

Treatment  External control  Reduction of sexual drives (depression/anxiety)  Cognitive Behaviour Therapy  Dynamic Psychotherapy .

exertion equal to climbing two flights of stairs) can be tolerated without severe shortness of breath or chest paro.g.  Sexual positions that produce the least exertion in the patient (e. . sexual activity can be resumed after a heart attack.SEXUALITY AND ILLNESS Heart disease and myocardial infarction (MI)  Men who have a history of MI often have erectile dysfunction. if exercise that raises the heart rate to 110-130 beats per minute (e.g...  Generally. the partner in the superior position) are the safest after MI. Both men and women who have a history of MI may have decreased libido because of side effects of cardiac medica-tions and fear that sexual activity will cause another heart attack.

SEXUALITY AND ILLNESS Diabetes  One quarter to one half of all diabetic men (more commonly older patients) have erectile dysfunction. b. Poor metabolic control of diabetes is related to increased incidence of sexual problems. a. . psychological factors also may influence erectile problems associated with diabetes. d. c. Sildenafil citrate and related agents often are effective in diabetes-related erectile disorders. Although physiologic causes are most important. Orgasm and ejaculation are less likely to be affected. Erectile problems generally occur several years after diabetes is diagnosed but may be the first symptom of the disease.  The major causes of erectile dysfunction in men with diabetes are vascular changes and diabetic neuropathy caused by damage to blond vessels and nerve tissue in the penis as a result of hyperglycemia.

.  in women cause problems with vaginal lubrication.SEXUALITY AND ILLNESS Spinal cord injury  in men cause erectile and orgasmic dysfunction. reduced testosterone levels. Fertility is not usually adversely affected. and orgasm. retrograde ejaculation (into the bladder). and decreased fertility. pelvic vasocongestion.

However. local application to the vagina of moisturizing agents can be helpful. In women. and vaginal dryness. shortening of vaginal length. which can reverse these vaginal changes. Hormone replacement therapy.  1. and need for more direct stimulation. these changes include vaginal thinning. In men. these changes include slower erection. longer refractory period. is used less frequently now than in the past.alterations in sexual functioning normally occur with the aging process.SEXUALITY AND AGEING Physical changes .  3. diminished intensity of ejaculation.  2. .

and loss of the sexual partner due to illness or death. sexual interest usually does not change significantly with increasing age. . Continued sexual activity is associated with good health. societal attitudes. Prolonged abstinence from sex leads to faster physical atrophy of the genital organs in old age.  2.SEXUALITY AND AGEING Sexual interest and activity  1. In spite of physical changes.

. b. the fewest sexual problems are found with use of angiotensin-converting enzyme (ACE) inhibitors (e. Dopamine may enhance sexuality. this may in turn depress sexuality. Antipsychotics.. Antihypertensives. orgasm. its blockade may decrease sexual functioning.. propranolol). captopril). particularly SSRIs.  3. and other sexual functions. erection. Prescription drugs that lead to decreased sexual function include  1.g. ejaculation. particularly dopamine-2 receptor blockers a. Prolactin levels increase as a result of dopamine blockade.. often as a result of their effects on neurotransmitter systems . particularly a-adrenergic agonists (e. Prescription drugs affect libido. B.g.  2. since serotonin may depress sexuality and delay orgasm.g. methyldopa) and (3-adrenergic blockers (e. Antidepressants.SEXUALITY AND MEDIACATION A.

Heroin and.  b. retarded ejaculation. and failure to ejaculate. Chronic use of marijuana may reduce testosterone levels in men and pituitary gonadotropin levels in women. . resulting in increased estrogen availability and sexual dysfunction in men.  2.  3. With long-term use. Amphetamines and cocaine increase sexuality by stimulating dopaminergic systems. Drugs of abuse  1. alcohol may cause liver dysfunction.SEXUALITY AND MEDIACATION C. to a lesser extent. Alcohol and marijuana increase sexuality in the short term by decreasing psychological inhibitions.  a. methadone are associated with suppressed libido.

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