Seminar on sexual

disorder
Presentor ;Zekariyas A
Natinael B
Alazar M
Rahel M

Moderator; Dr Ashenafi Negash

(MD,Psychiatrist)
NORMAL SEXUALITY

PRESENTOR:ZEKARIYAS A
outline
• Normal sexuality
• Childhood sexuality
• Psychosexual factors
• CNS and sexual behavior
• Physiologic response
• Gender difference in desire and erotic stimuli
Normal Sexuality
• Sexuality has always been an area of interest to the
medical community in different eras.
• Sexuality is determined by anatomy, physiology, the
culture in which a person lives, relationships with
others, and developmental experiences throughout
the life cycle.
• Normal sexual behavior brings pleasure to oneself
and one’s partner and involves stimulation of the
primary sex organs including coitus
• it is devoid of inappropriate feelings of guilt or
anxiety and is not compulsive.
• Sexuality and total personality are so entwined that
to speak of sexuality as a separate entity is virtually
impossible.
• The term psychosexual applies to more than sexual
feelings and behavior, and it is not synonymous
with libido in the broad Freudian sense
CHILDHOOD SEXUALITY
• Before Freud described the effects of childhood
experiences on personalities of adults, the
universality of sexual activity and sexual learning in
children was unrecognized.
• Most sexual learning experiences in childhood
occur without the parents’ knowledge, but
awareness of a child’s sex does influence parental
behavior
• During a critical period in development, infants are
especially susceptible to certain stimuli;
• later, they may be immune to these stimuli.
• The detailed relation of critical periods to
psychosexual development has yet to be
established;
• Freud’s stages of psychosexual development—
oral, anal, phallic, latent, and genital—presumably
provide a broad framework.
PSYCHOSEXUAL FACTORS
• Sexuality depends on four interrelated
psychosexual factors:
 sexual identity,
 gender identity,
 sexual orientation, and
 sexual behavior.
• These factors affect personality, growth,
development, and functioning.
Sexual Identity and Gender
Identity
• Sexual identity is the pattern of a person’s biological
sexual characteristics: chromosomes,
• external genitalia,
• internal genitalia,
• hormonal composition,
• gonads, and
• secondary sex characteristics
• Gender identity is a person’s sense of maleness or
femaleness.
• Sexual identity and gender identity are interactive.
Classification of Intersexual Disordersa

• Turner’s syndrome
• Klinefelter’s syndrome
• Androgen insensetivity syndrome
• Enzymatic defects in XY genotype
• Hermaphroditism
• psedohermaphroditism
Sexual Orientation
• Sexual orientation describes the object of a
person’s sexual impulses:
• heterosexual (opposite sex),
• homosexual (same sex), or
• bisexual (both sexes).
• A group of people have defined themselves as
“asexual” and assert this as a positive identity.
• Some researchers believe this lack of attraction to
any object is a manifestation of a desire disorder.
• Other people wish not to define their sexual
orientation at all and avoid labels. Still others
• describe themselves as polysexual or pansexual.
 Sexual Behavior
The Central Nervous System and
Sexual Behavior
THE BRAIN
• Cortex. The cortex is involved both in controlling
sexual impulses and in processing sexual stimuli.
• In studies of young men, some areas of the brain have
been found to be more active during sexual
stimulation than others.
• These include
• the orbitofrontal cortex, which is involved in
emotions;
• the left anterior cingulate cortex, which is involved
in hormone control and sexual arousal; and
• the right caudate nucleus, whose activity is a factor
in whether sexual activity follows arousal.
• Limbic System. In all mammals, the limbic system is
directly involved with elements of sexual functioning.
Chemical or electrical stimulation of
• the lower part of the septum and the contiguous
preoptic area,
• the fimbria of the hippocampus,
• the mammillary bodies, and
• the anterior thalamic nuclei have all elicited penile
erections.
• Studies of the brain in women have revealed that
those areas activated by emotions of fear or anxiety
are notably quiescent when the woman
experiences an orgasm.
• Brainstem. Brainstem sites exert inhibitory and
excitatory control over spinal sexual reflexes.
• Brain Neurotransmitters. Many neurotransmitters,
including dopamine, epinephrine, norepinephrine,
and serotonin, are produced in the brain and affect
sexual function.
• SPINAL CORD. Sexual arousal and climax are
ultimately organized at the spinal level.
• Sensory stimuli related to sexual function are
conveyed via afferents from the pudendal, pelvic,
and hypogastric nerves
Physiological Responses
• Sexual response is a true psychophysiological
experience.
• Arousal is triggered by both psychological and
physical stimuli.
• Psychosexual development, psychological attitudes
toward sexuality, and attitudes toward one’s sexual
partner are directly involved with, and
• affect, the physiology of human sexual response.
• Normally, men and women experience a sequence of
physiological responses to sexual stimulation.
• physiological process involves increasing levels of
vasocongestion and myotonic (tumescence) and the
subsequent release of the vascular activity and
muscle tone as a result of orgasm (detumescence).
• A sexual fantasy or the desire to have sex frequently
precedes the physiological responses of excitement,
orgasm and resolution.
• In addition, a person’s subjective experiences are as
important to sexual satisfaction as the objective
physiologic response.
HORMONES AND SEXUAL
BEHAVIOR
• In general, substances that increase dopamine levels in the
brain increase desire, whereas substances that augment
serotonin decrease desire.
• Testosterone increases libido in both men and women,
although estrogen is a key factor in the lubrication involved
in female arousal and may increase sensitivity in the woman
to stimulation.
• Recent studies indicate that estrogen is also a factor in the
male sexual response and that a decrease in estrogen in the
middle-aged male results in greater fat accumulation just as
it does in women.
• Progesterone mildly depresses desire in men and women as
do excessive prolactin and cortisol. Oxytocin is involved in
pleasurable sensations during sex
GENDER DIFFERENCES IN
DESIRE AND EROTIC STIMULI
• Sexual impulses and desire exist in men and women.
• In measuring desire males generally possess a higher
baseline level of desire than women, which may be
biologically determined.
• Motivations for having sex,other than desire, exist in
both men and women, but seem to be more varied and
prevalent in women.
• In women they may include a wish to reinforce the pair
bond, the need for a feeling of closeness, a way of
preventing the man from straying, or a desire to please
the partner.
• Although explicit sexual fantasies are common to both
sexes, the external stimuli for the fantasies frequently
differ for men and women.
• Many men respond sexually to visual stimuli of nude
or barely dressed women.
• Women report responding sexually to romantic
stories such as a demonstrative hero whose passion
for the heroine impels him toward a lifetime
commitment to her.
Sexual Dysfunctions

29
Introduction

 A person’s inability “to participate in a sexual

relationship as he or she would wish. (ICD-
10).
 The essential features of sexual dysfunctions
are an inability to respond to sexual
stimulation, or the experience of pain during
the sexual act.

30
Introduction

 Forms of sexual dysfunctions include ;

 Male hypoactive sexual desire disorder
 Female sexual interest/arousal disorder
 Erectile disorder
 Female orgasmic disorder
 Delayed ejaculation or premature (early)
ejaculation
 Genito-pelvic pain/penetration disorder
 Substance/medication induced sexual dysfunction

31
Introduction
Causes can be :
 Psychological factors
 Physiological factors
 Combined factors
 Stressors

32
Introduction
Mental disorders causing sexual dysfunction :
 Depressive disorders
 Anxiety disorders
 Personality disorders
 Schizophrenia

33
Introduction

• If the dysfunction is largely attributable to an

underlying psychiatric disorder, only the underlying
disorder should be diagnosed.

34
Introduction
• Sexual dysfunctions are usually self-perpetuating.

• The sexually functional partner often reacts with

distress or anger due to feelings of deprivation or a
sense that he or she is an insufficiently attractive or
adequate sexual partner.

35
Divorce: Its cause and impact on the life of
divorced women and children

• Among the causes of divorce, husband’s addiction

to chat, alcohol, smoking and economic problem
contributed the larger share. In addition, sexual
incompatibility, fertility problem of both couples,
pressure from friends and families on the couples
and difference in religious and ethnic background
reported.
37
Male Hypoactive Sexual Desire
Disorder

38
Male Hypoactive Sexual Desire Disorder

 A deficiency or absence of sexual fantasies and

desire for sexual activity for a minimum duration of
approximately 6 months.
 Is greatest at the younger and older ends of the age
spectrum
 Only 2 percent of men ages 16 to 44 affected by this
disorder.
 A reported 6 percent of men ages 18 to 24, and 40
percent of men ages 66 to 74

39
Male Hypoactive Sexual Desire
Disorder
• Decreased desire isn’t the same to decreased activity.

40
Male Hypoactive Sexual Desire Disorder

• Medications (SSRIs, 5 –alpha reductase

inhibitors)
• Alcoholism
• Fatigue
• Recreational drugs
• Testosterone deficiency

41
Etiology
 Vagina dentata- Inhibition of desire
 Chronic stress, anxiety, or depression
 Abstinence from sex for a prolonged period
 The sign of a deteriorating relationship

42
43
Female Sexual Interest/Arousal
Disorder
• women do not necessarily move stepwise from
desire to arousal, but often experience desire
synchronously with, or even following, beginning
feelings of arousal.
• women experiencing sexual dysfunction may
experience ,
• either/or both inability to feel interest or arousal, and
• they may often have difficulty achieving orgasm or
experience pain in addition.

44
Epidemiology

• Lifelong sexual desire disorders among women may

involve 15% but are less frequent among men.
• Acquired desire disorders among older individuals
are probably three times as common.

45
Etiology
• Hormonal:dopamine, testosterone, estrogen
↑desire
• Serotonine, prolactine ↓desire
• Medication antipsychotic

46
47
48
Evaluation
• A patient’s age
• General health
• Any medication regimen
• Life stresses (cultural norms, Relationship
conflicts)
• A baseline of sexual interest before the
disorder began
• Dx should not be made unless the lack of
desire is a source of distress to a patient.

49
Treatment
• Life style changes
• Psychotherapy
• Treat the possible coexisting illnesses or conditions

50
51
Focus on
• Anatomy and Physiology of erection
• Definition and epidemiology of ED
• Etiology
• Diagnosis
• Treatment

52
Definition
• Male erectile disorder(MED)
• used to called erectile dysfunction/Impotence
• Male erectile disorder is the inability to achieve or
sustain a penile erection sufficient to complete
sexual activity, and the inability must be either
persistent or recurring with the result of marked
distress or problems with interpersonal
relationships

53
Types of male erectile disorder
• Lifelong Vs. Acquired or 20
• Generalized Vs. Situational
• mild, moderate, severe

54
Epidemiology
• Acquired >>>lifelong
• 10 to 20 % of all men
• ED is the chief complaint of > 50% of all men treated for
sexual disorder
• Incidence increases with age
• 2 to 8 % of the young adult population
• 40 to 50 percent in men b/n ages of 60 and 70 while 75
% at age 80

55
Risk factors for acquired ED
 Age
 Smoking
Exercise,
DM

56
Causes
• Organic(Structural usually in old)
• Psychological (usually in young and middle-aged
men)
• both(majority)

57
Organic Causes of ED
• Local Genital Pathology
1.Congenital malformations
2. Surgical procedures e.g.
perineal prostatectomy
3. Elephantiasis
Endocrine Disorders
1. Diabetes mellitus
2. Testicular atrophy, e.g.
secondary to cirrhosis,
3. Thyroid dysfunction.
Neurological Disorders
1. Autonomic neuropathy,
e.g. DM, Alcohol,
polyneuropathy
2. Spinal cord lesions, e.g.
transverse myelitis
3. tumours
4. Brain damage
58
Psychological causes
• include current relationship problems, stress,
comorbid with other psychiatric disorders, such as
depression, and anxiety (e.g., guilt, performance
anxiety),personality disorders, and schizophrenia,
• In men with erectile disorder, the presence of
morning erection, erections during masturbation,
or erections during rapid eye movement (REM)
sleep suggests a psychological rather than a
physical cause

59
dx…
Hx
• Onset, duration
• Psychological evaluation_ Comorbidity, substance
• Medical illness, surgery, Drug
PE
• Body habitus BP, Detail examination of
CVS ,Abdomen , Neurology
• External genitalia, DRE(>50yrs)

60
Lab.Diagnostic markers
• Recommended _ FBS, hormone profile, serum lipid

 Vascular integrity… Doppler u/s

61
62
Dx Criteria DSM-V
A. At least one of the three following symptoms must be
experienced on almost all or all (approximately 75%-100%)
occasions of sexual activity (in identified situational
contexts or, if generalized, in all contexts):
1. Marked difficulty in obtaining an erection during sexual
activity.
2. Marked difficulty in maintaining an erection until the
completion of sexual activity.
3. Marked decrease in erectile rigidity.

B. The symptoms in Criterion A have persisted for a minimum

of 6 months.

63
C .The symptoms in Criterion A cause clinically
significant distress in the individual.

D. The sexual dysfunction is not better explained by a

non-sexual mental disorder or as a consequence of
severe relationship distress or other significant
stressors and is not attributable to the effects of a
substance/medication or another medical condition.

64
Specify whether:

Lifelong: The disturbance has been present since the individual became sexually
active

Acquired: The disturbance began after a period of relatively normal sexual

function.

Specify whether:
Generaiized: Not limited to certain types of stimulation, situations, or partners.
Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

Mild: Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress over the symptoms in Criterion A.
Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

65
Treatment
• Lifestyle modification
• Identify and treat underlining cause
• Therapy for assisted erection
_ psychotherapy+Pharmacologic

66
Psychosexual therapy
• Relaxation techniques, Systematic desensitization
used to reduce anxiety
• Inform regarding sex education, partner
communication,and sexual behavioral therapy

67
Pharmacologic
• First line _ PDE-5 Inhibitors (sildenafil citrate
(Viagra)vardenafil (Levitra, Nuviva) and tadalafil
(Cialis).
_

68
 Mechanical ,Surgical
• Second line _Vacuum-assisted erection devices, occlusive rings.
_ Intracorporal injection of vasodilators
• for end stage ED _ penile prosthetic devices
_ penile transplant

69
Vacuum constriction devices

70
Orgasmic disorder

PRESENTOR ;ALAZAR M
 outline
• Definition
• Orgasm disorders
• Epidemiology
• Diagnosis
• Treatment approach
 Orgasm
• Orgasm is sudden discharge of accumulated sexual
excitement during sexual response cycle resulting in
rhythmic muscular contraction in pelvic region
characterized by sexual pleasure and v/s change.

• orgasm is the climax of the sexual response

cycle.it is the third phase in the sex cycle.
Physiological changes during
orgasm
• Involuntary muscle contractions begin
• Blood pressure, heart rate, and breathing are at
their highest rates, with a rapid intake of oxygen.
• There is a sudden, forceful release of sexual
tension.
• In women, the muscles of the vagina contract. The
uterus also undergoes rhythmic contractions.
• In men, rhythmic contractions of the muscles at the
base of the penis result in the ejaculation of semen.
• A rash, or "sex flush" may appear over the entire
body.
Orgasm disorders

female orgasm disorder

delayed ejaculation /retarded ejaculation
premature ejaculation
Female orgasm disorder
Definition
• Female orgasm disorder : sometimes called
inhibited female orgasm or anorgasmia ,is recurrent
or persistent inhibition of female orgasm which is
manifested by absence or delay orgasm after
normal excitement phase in intensity, duration and
focus
• in short, a woman’s inability to achieve orgasm by
masturbation or coitus.
Epidemiology
• Overall prevalence 10%
• 5% of married women
• Some research 30%
• Life long disorder is common among unmarried
than married .
• Increased orgasm in age greater than 35 because of
less physiological inhibition, increased experience
or both.
• some anorgasmic women are not distressed by the
lack of climax and derive pleasure from sexual
activity .
• woman may present with this complaint because her
partner is bothered by her lack of orgasm.
 Causes
• Sociocultural_ cultural expectations and social
restriction grow up to believe sexual pleasure not
natural entitlement for so-called descent women
• Psychological _fear of pregnancy, rejection by sex
partner, damage to vagina ,hostility towards men,
poor body image ,feeling of guilt for sexual impulse
Some women equates orgasm with lose of control,
aggressiveness ,destructive or violent impulse; their
fear of this impulse cause inhibition orgasm or
arousal.
• Physiological
Diagnostic Criteria(DSM-5)
A. Presence of either of the following symptoms and
experienced on almost all or all (ap­ proximately 75%-
100%) occasions of sexual activity (in identified
situational contexts or, if generalized, in all contexts):
1. Marked delay in, marked infrequency of, or absence
of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
B. The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months.
 continued
C. The symptoms in Criterion A cause clinically
significant distress in the individual.
D. The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of
severe relationship distress (e.g., partner violence)
or other significant stressors and is not attributable
to the effects of a substance/medication or another
medical condition.
 Continued
Specify whether:
• Lifelong: The disturbance has been present since the
individual became sexually active.
• Acquired: The disturbance began after a period of
relatively normal sexual function.
Specify whether:
• Generalized: Not limited to certain types of
stimulation, situations, or partners.
• Situational: Only occurs with certain types of
stimulation, situations, or partners.
continued
• Specify if: Never experienced an orgasm under any
situation.
• Specify current severity:
• Mild: Evidence of mild distress over the symptoms
in Criterion A.
• Moderate: Evidence of moderate distress over the
symptoms in Criterion A.
• Severe: Evidence of severe or extreme distress over
the symptoms in Criterion A.
delayed ejaculation/retarded
ejaculation
• A man achieves ejaculation during coitus with great
difficulty.
• Some researchers think that delayed ejaculation should
be differentiated from orgasm disorder
• Specially when there is ejaculation but absence or
markedly decreased subjective sense of pleasure during
orgasmic experience
• Which is called orgasmic anhedonia
• The definition of "delay" does not have precise
boundaries
Epidemiology
• Incidence of orgasm disorder is less than premature
ejaculation and erectile disorder
• Prevalence in general population is 5%
• It increase with use of antidepressant,SSRI,
pornography site
 Causes
• Psychopathology such as attention deficit
disorder,OCD
• Sociocultural and religious factor _genital as dirty
and Sex as sinful act
• Other such loss of sexual attraction to partner,
hostility towards women , commitment for sexual
performance , plan for pregnancy in which the male
is ambivalent
Diagnostic Criteria
A. Either of the following symptoms must be
experienced on almost all or all occasions
(approximately 75%-100%) of partnered sexual
activity (in identified situational con­texts or, if
generalized, in all contexts), and without the
individual desiring delay:
1. Marked delay in ejaculation.
2. Marked infrequency or absence of ejaculation.
B. The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months
continued
C. The symptoms in Criterion A cause clinically
significant distress in the individual.
D. The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of
severe relationship distress or other significant
stressors and is not attributable to the effects of a
substance/medication or another medical condition
continued
Specify whether:
• Lifelong: The disturbance has been present since the
individual became sexually active.
• Acquired: The disturbance began after a period of
relatively normal sexual function.
Specify whether:
• Generalized: Not limited to certain types of
stimulation, situations, or partners.
• Situational: Only occurs with certain types of
stimulation, situations, or partners.
continued
• Specify current severity:
Mild: Evidence of mild distress over the symptoms
in Criterion A.
Moderate: Evidence of moderate distress over the
symptoms in Criterion A.
Severe: Evidence of severe or extreme distress over
the symptoms in Criterion A.
Management principles
• Depends on types, severity, and cause
• Psychotherapy
• Treat underlying cause
Premature (Early) Ejaculation
• In premature ejaculation, men persistently or
recurrently achieve orgasm and ejaculation before they
wish to.
• The diagnosis is made when a man regularly ejaculates
before or within approximately 1 minute after vagina
penetration.
• Ejaculation that occurs sooner than desired(IELT<1min)

• Loss of control over ejaculation and

• Causes distress to either one or both partners
 Epidemiology

• Most common form of sexual dysfunction

• Prevalence Rates vary from 4-39% ; most
general studies in 21-31% range
• Rates generally not affected by age, marital
status, race, or country of residency
• more commonly reported among college-
educated men than among men with less
education
 What Causes PE
• Exact etiology not fully known

• Combination of Physiologic and Psychological

Factors
• Primary PE – “more” neurophysiologic while
acquired PE “more” psychological or related to a
medical condition .
• Previous sexual experience(conditioned behavior)
 (Diagnostic Criteria-DSM-5 )
A persistent or recurrent pattern of ejaculation occurring
during partnered sexual activity within approximately 1
minute following vaginal penetration and before the
individual wishes it.
Note: Although the diagnosis of premature (early) ejaculation
may be applied to individuals engaged in non vaginal sexual
activities, specific duration criteria have not been established
for these activities.
B. The symptom in Criterion A must have been present for at
least 6 months and must be experienced on almost all or all
(approximately 75%-100%) occasions of sexual activity (in
identified situational contexts or, if generalized, in all
contexts).
continued
C. The symptom in Criterion A causes clinically
significant distress in the individual.
D. The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of
severe relationship distress or other significant
stressors and is not a­ttributable to the effects of a
substance/medication or another medical condition
continued
Specify whether;
• Lifelong: The disturbance has been present since the
individual became sexually active.
• Acquired: The disturbance began after a period of
relatively normal sexual function.
Specify whether:
• Generalized: Not limited to certain types of
stimulation, situations, or partners.
• Situational: Only occurs with certain types of
stimulation, situations, or partners
continued
• Specify current severity:
• Mild: Ejaculation occurring within approximately 30
seconds to 1 minute of vaginal penetration.
• Moderate: Ejaculation occurring within
approximately 15-30 seconds of vaginal
penetration.
• Severe: Ejaculation occurring prior to sexual
activity, at the start of sexual activity, or within
approximately 15 seconds of vaginal penetration
 Treatment for PE

• Treat underlying cause

• Pharmacologic Interventions

• Behavioral interventions
Pharmacologic Interventions
• Topical anesthetics

• Tricyclic antidepressants (TCAs)

• Selective Serotonin Reuptake Inhibitors (SSRIs)

• Phosphodiesterase-5 (PDE-5) inhibitor

(Sildenafil, Tadalafil, Avanafil)
SEXUAL PAIN
DISORDERS
Genito-pelvic Pain or Penetration
Disorders

In DSM-5 this disorder refers to one or more of the following

complaints,
• difficulty having intercourse;
• fear of pain
• genito-pelvic pain
• and tension of the pelvic floor muscles

 Previously, these pain disorders were diagnosed as dyspareunia

or vaginismus
 Dyspareunia
• Is recurrent or persistent genital pain occurring before, during,
or after intercourse.
• Dyspareunia is related to vaginismus/coexist together.

• It is unclear exactly what causes vaginismus but it is thought

that past sexual trauma may play a role

• A pain disorder should not be diagnosed when an organic basis

for pain is found or when it is caused by a lack of lubrication.
• Chronic pelvic pain is a common complaint in
women with a history of rape or childhood sexual
abuse.

• Painful coitus can result from tension and anxiety

about the sex act that cause women to involuntarily
contract their pelvic floor muscles.

The pain is real and makes intercourse unpleasant or

unbearable.
 Vaginismus
• Defined as a constriction of the outer third of the
vagina due to involuntary pelvic floor muscle
tightening or spasm which interferes with penile
insertion and intercourse

• This response may occur during a gynecological

examination when involuntary vaginal constriction
prevents the introduction of the speculum into the
vagina.
• The diagnosis is not made when the dysfunction is
caused exclusively by organic factors or when it is
symptomatic of another mental disorder.
• Vaginismus may be complete, that is no
penetration of the vagina is possible, whether by
the penis, fingers, a speculum during gynecologic
exam.
• In a less severe form of vaginismus penetration may
be achieved with the smallest size speculum or little
fingers.
• In mild cases, the muscles relax after the initial
difficulty with penetration and the woman can
continue with sexual play, sometimes even with
coitus.
• Women with vaginismus may consciously wish to
have coitus, but unconsciously wish to keep a penis
from entering their bodies.
• Prone to have anal sex????
• Affect highly educated woman and higher
economical status
 causes(postulated)
• Sexual trauma(rape)
• Severe pain at first sexual experience
• Disharmonic relationships
• Childhood sever pain due to surgery or dental
intervention
DSM 5 :Diagnostic Criteria
A. Persistent or recurrent difficulties with one (or
more) of the following:
1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal
intercourse or penetration attempts.
3. Marked fear or anxiety about vulvovaginal or
pelvic pain in anticipation of, during, or as a result
of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor
muscles during attempted vaginal penetration.
B. The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months
C. The symptoms in Criterion A cause clinically
significant distress in the individual
D. The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of a
severe relationship distress (e.g., partner violence) or
other significant stressors and is not attributable to
the effects of a substance/medication or an­other
medical condition
cont
Specify whether:
Lifelong: (primary) The disturbance has been present since the
individual became sexually active.
Acquired:(secondary) The disturbance began after a period of
relatively normal sexual function.
Specify current severity:
Mild: Evidence of mild distress over the symptoms in Criterion A.
Moderate: Evidence of moderate distress over the symptoms in
Criterion A.
Severe: Evidence of severe or extreme distress over the
symptoms in Criterion A.
treatment
• individual and group psychosexualtherapy

• technics such as dilators

• pharmacotherapy if associated with high level of

anxiety from their conditions
Medical conditions associated
with sexual dysfunction
Medical condition can affect
• Libido/desire
• Erection
• Ejaculation
Male
Erectile dysfunction 40-70 yrs (52%)
Risk factors
DM, obesity, HTN, , BPH, Atherosclerosis
Smoking
Surgery and radiation
MEDICAL CONDITON

• Vasculogenic
The most common organic cause of ED
Due to disturbance of blood flow to and from the
penis
DM, dyslipidemia, traumatic, HTN
• Neurogenic
Disorders that affect the sacral spinal cord or the
autonomic nervous system relaxation of penile
smooth muscle, thus leading to ED.
• Spinal cord injury(75%)
• MS
• Neuropathy
• Surgery
Pharmacological Agents
Implicated In Sexual Dysfunction
• Antipsychotic Drugs
• Antidepressant Drugs
• Sympathomimetics
• α-Adrenergic and β-Adrenergic Receptor
Antagonists
• Anticholinergics
• Antihistamines
• Antianxiety Agents
• Alcohol
• Opioids
• Hallucinogens
• Cannabis
• Barbiturates and Similarly Acting Drugs
Treatment
• Sildenafil, Tadalafil, Avanafil
• Treat underlying conditions.
• Removing the offending drug
Female
• Neurologic – stroke, spinal injury, Parkinson's
• Trauma, surgery, radiation
• DM, hyperprolactinemia
• Liver and renal failure
• CVDs
• drugs

• Treatment; treating the cause

hormonal therapy
Paraphilic Disorders

PRESENTOR:RAHEL MESERET
 Introduction
Paraphilia's/perversions are recurrent, intense, sexually arousing
fantasies, urges, or stimuli that are deviated from normal sexual
behaviors.
Paraphilics do not experience arousal and orgasm to stimuli that
are typically considered erotic.
DSM-5 only considers paraphilia a disorder when
A person has acted on the fantasy or impulse, or
If the fantasies or impulses lead to significant distress.
Resulting in negative consequences or psychosocial impairment.
 Epidemiology
Paraphilias are rare, but the insistent, repetitive
nature of the disorders gets attention.
The prevalence may be much higher than that found in
clinical care.
As usually defined, the paraphilias seem to be mostly
male conditions.
More than 50 % of all paraphilias have their onset before
age 18.
The occurrence peaks between ages 15 and 25 and
gradually declines.
 Cont…
Paraphiliacs frequently have three to five paraphilias,
either concurrently or at different times in their lives.
Of adult females, 20 % have been the targets of
exhibitionists and voyeurisms.
Among legally identified cases of paraphilic disorders,
pedophilia is most common.
Sexual sadism usually comes to attention only in
sensational cases of rape, brutality, and lust murder.
 Etiology
Psychosocial Factors.
Many paraphilias can be traced back to childhood
experiences.
Molestation as a child can predispose to accept
continued abuse as an adult or, conversely, to
become an abuser of others.
In the classic psychoanalytic model, persons with a
paraphilia have failed to complete the normal
developmental process toward sexual adjustment.
 Cont…
Biologic Factors.
Several studies have identified abnormal biologic
findings in persons with paraphilias including
Abnormal hormone levels (high androgens),
chromosomal abnormalities, seizures, abnormal EEG
studies, major mental disorders, and an intellectual
disorder.
It is not clear whether these abnormalities are
causally related or incidental to the paraphilia.
 The Clinical Presentation and Diagnosis
In DSM-5, for each, but general speaking criteria- A with at
least B or C.(If only A is met-paraphilia not a disorder)
A. Intense and recurrent arousal from their deviant
fantasy for at least 6 months and
B. To either act on the paraphilic impulse or experience
significant distress as a result of the impulse, or
C. Negative consequences / psychosocial impairment
D. Specifiers
Symptom- Sexual activity to dehumanized objects.
Severity- In controlled environment
Course-In full remission no symptoms for at least 5
years
Presentations
Almost all are male
Usually onset is at teens - twenties
Strong sex drive
Fantasize about or hold object during sex
Frequently have more than one paraphilia
Intimacy problems, & personality disturbances
Comorbidities- (mood disorders, Psychotic disorders, social
phobia, GAD, Panic attack, PTSD, ADHD, conduct disorder,
substance use disorder,)
DSM-5 lists 8 paraphilic disorders with explicit diagnostic
criteria because of their threat to others or because are
relatively common.
Exhibitionism
Voyeurism
Frotteurism
Transvestism
Fetishism
Pedophilia
Sexual sadism, and
Sexual masochism
Many others also exist.
 Exhibitionism
It is the recurrent urge to expose the genitals to a
stranger or an unsuspecting person.
Sexual excitement occurs in anticipation of the
exposure and orgasm is brought about by masturbation
during or after the event.
Almost all are men exposing themselves to women.
To assert their masculinity by showing their penises
and by watching the victims’ reactions like fright,
surprise, and disgust.
Specify whether
Sexually aroused by exposing genitalia to prepubertal
children, to physically mature individuals or both.
 Voyeurism
It is the recurrent preoccupation with fantasies and acts
that involve observing unsuspecting persons who are
naked, engaged in grooming or sexual activity.
Masturbation to orgasm usually accompanies or
follows the event.
The first voyeuristic act usually occurs during
childhood and the paraphilia is most common in men.
 Frotteurism
It is usually characterized by a man’s rubbing his
penis against the buttocks or other body parts of a
non consenting fully clothed woman to achieve orgasm.
The acts usually occur in crowded places, particularly in
subways and buses.
 Frottage is often their only source of sexual
gratification.
 Transvestism
It is described as fantasies and sexual urges to dress
in opposite gender clothing as a means of arousal and
as an adjunct to masturbation or coitus.
More often seen around pubescence or in
adolescence.
DSM specifier with fetishism: aroused by fabrics, material
or garment
With auto gynephilia: aroused by thought or images of self
as female
 Fetishism

In fetishism, the sexual focus is objects (e.g., shoes,

gloves, underwear, and stockings) that are intimately
associated with the human body, or on non-genital
body parts (e.g foot).
The particular fetish used is linked to someone
closely involved with a patient during childhood.
The patient may direct sexual activity at the fetish itself
or may incorporate the fetish into sexual intercourse.
The disorder is almost exclusively found in men.
Specifiers: body part(s); nonliving objects; other.
 Pedophilia
It involves recurrent intense sexual urges toward, or
arousal by prepubescent children.
 DSM-5, the child must be under 14 years old, and
the patient must be at least 16 years old and at least five
years older than the victims.
Most child molestations involve genital fondling or
oral sex.
Vaginal or anal penetration of children infrequently
occurs, except in cases of incest.
Due to the referral process most child victims coming to
public attention are girls.
 Cont….

Pedophiliacs are mostly heterosexual and 50 percent have

consumed alcohol to excess at the time of the
incident and may have concomitant or previously
committed exhibitionism, voyeurism or rape.
Incest is related to pedophilia by the frequent
selection of an immature child as a sex object.
 Sexual Sadism
It is recurrent and intense sexual arousal from the
physical and psychological suffering of another person.

A person must have experienced sadistic fantasies for

at least 6 months and must have either acted on or
experienced significant distress to be diagnosed of
sexual sadism disorder.
The onset is usually before the age of 18 years, and
most persons with sexual sadism are male.
Cont…
Sexual sadism likely derives from early abusive life
experiences.
It is related to rape, although rape is more aptly
considered an expression of power.
Some sadistic rapists, however, kill their victims after
having sex (so-called lust murders).
In many cases, these persons have underlying
schizophrenia, and they may also suffer from a
dissociative disorder or have a history of head trauma.
 Sexual Masochism
Masochists have a recurrent preoccupation with sexual
urges and fantasies involving the act of being
humiliated, beaten, bound or otherwise made to
suffer.
More common among men than among women.
Masochists may have had childhood experiences that
convinced them that pain is a prerequisite for sexual
pleasure.
About 30 percent of masochists also have sadistic
fantasies.
Specify if: asphyxiophilia or autoerotic asphyxiation
 Other Specified Paraphilic Disorder
DSM-5 also includes a generalized category for
paraphilias that cause distress but do not fit into one
of the previous categories.
Telephone and Computer Scatologia.
Necrophilia
Partialism (A.K.A Oralism)
Cunnilingus, fellatio, anilingus.
Zoophilia, as an organized paraphilia, is rare.
Coprophilia, coprophagia
Urophilia, and Klismaphilia (enema)
Hypoxyphilia, Autoerotic asphyxiation
 Differential Diagnosis
Clinicians must differentiate a paraphilia from an
experimental act that is not recurrent or compulsive
and done for its novelty.
DSM-5 suggests the paraphilia designation be reserved
for those ages 18 and older to avoid pathologizing
healthy sexual curiosity and occasional experimentation
in adolescence.
Paraphilic activity most likely begins during
adolescence.
Some paraphilias are associated with other mental
disorders, such as schizophrenia.
Brain diseases can also release perverse impulses.
 Course and Prognosis
Controlling or curing paraphilic disorders is difficult due
to the fact that it is hard assuring people that alternative
approaches will be as sexually gratifying.
A poor prognosis for paraphilic disorder is associated with
an early age of onset, a high frequency of acts, no guilt or
shame about the act, and substance abuse.
The course and the prognosis are better when patients
have a history of coitus in addition to the paraphilia, and
when they are self-referred rather than referred by a legal
agency.
 Treatment
Five types of psychiatric interventions:
1. External control
2. Reduction of sexual drives
3. Treatment of comorbid conditions (e.g., depression
or anxiety),
4. Cognitive-behavioral therapy,
5. Dynamic psychotherapy.
 References
Kaplan &Shaddock's Synopsis of Psychiatry- Twelfth Edition
Synopsis of psychiatry –Eleventh Edition
DSM-5-the big book
internet
THANK YOU!!!