Sexual disorders for psychiatry students

Human Sexuality and Sexual Dysfunctions
Alemu L
MSc fellow @ University of Gondar ,CMHS
Department of psychiatry
May 24, 2019by Alemu L
1

Objectives
At the end of this lesson learners are expected
To explain normal human sexuality
To describe sexual dysfunction and paraphilia
To list types of sexual disorder
To identify types of paraphilia
2

Introduction
 Sexual relationships are among the most sensitive and delicate
issues in human relationships.
Normal sexual behavior brings pleasure to oneself and one's
partner.
It is devoid of inappropriate feelings of guilt or anxiety and is
not compulsive.
3

Sexual behavior has many meanings and purposes:-
Reproductive /biological/
Expression of emotion /psychological/
Commitment to each other and the offspring /social/
4

Male Anatomy
 Freud referred to the penis as the executive organ of sexuality.
Size of the penis varies within a fairly constant range.
Ranges 7 to 11 cm in the flaccid state and 14 to 18 cm in the erect state
Concern over the size of the penis is practically universal among men.
The circumcised penis, with its exposed glans, was once believed to be
less sensitive, and porn to premature ejaculation , but research found this
wrong now a days. May 24, 2019
by Alemu L
5

Female Anatomy
Clitoris is primary female sexual organ.
 This is because of orgasm depends physiologically on adequate clitoral
stimulation.
The vagina is usually collapsed, approximately 8 cm long.
During sexual intercourse, expands in both length and width.
After menopause vagina loses much of its elasticity.
The size of the clitoris varies considerably and is unrelated to the sexual
responsiveness.
6

Brain Anatomy
Cortex: involved both in controlling sexual impulses and in processing
sexual stimuli.
involved in hormone control and sexual arousal.(cingulate cortex)
 Limbic System:directly involved with elements of sexual functioning.
Brainstem: exert inhibitory and excitatory control over spinal sexual
reflexes.
 SPINAL CORD: Sensory stimuli Sexual arousal and climax are ultimately
organized at the spinal level.
7

Sexuality physiology
coitus
The first coitus is a rite of passage for both men and women.
 In the United Sates the overwhelming majority of people have experienced
coitus by young adulthood, by their early 20s.
The young man experiencing intercourse for the first time is vulnerable in his
pride and self-esteem.
Cultural pressure on the woman with her first coitus reflects remaining
cultural ambivalence about her loss of virginity, despite the current era of
sexual liberality.
May 24, 2019
8

Coitus….
This is demonstrated in the statistic that only 50 percent of young
women use contraception during their first coitus, and of that 50
percent, an even smaller number use it consistently thereafter.
Young women with a history of masturbation are more likely to
approach intercourse with positive anticipation and confidence.
9

Sexuality physiology…
Ejaculation is the forceful propulsion of semen and seminal fluid into the
urethra.
Passage of fluid into the penile urethra provide the man with a sensation of
impending climax.
The ejaculate is propelled through the penile urethra by contractions of the
pelvic and perineal muscles.
It is believed that the larger the ejaculate, the more pleasurable the orgasm,
but this belief is highly subjective.
10

Sexuality physiology
Testosterone is the hormone believed to be connected with libido
in both men and women.
In men, stress is inversely correlated with testosterone blood
concentration.
Other factors, such as sleep, mood, and lifestyle, influence
circulating levels of the hormone
11

Sexuality physiology ….
The effects of estrogen in the female and androgen in the male are
necessary for the development of ova and spermatozoa, respectively
 The defining hormonal difference between women and men is the
quantity of these hormones present in the sexes
Men make 20 times as much androgen as do women, and women do
200 times as much estrogen as do men
These cellular identities have relevance to sexual behavior, sexual
identity, partner choice
12

Psychosexual Factors
 Sexuality depends on four interrelated psychosexual factors:
 Sexual identity,
 gender identity,
 sexual orientation, and
 sexual behavior
13

Sexual behavior
includes desire, fantasies, pursuit of partners all the activities engaged in
to express and gratify sexual needs
o It is psychological and physiological responses to internal and external
stimuli.
Masturbation: usually is a normal precursor of object-related sexual
behavior and a form of sexual pleasure
Greco-Roman writers recommended masturbation as a healthful practice
for both men and women
14

Masturbation …
The prohibition against masturbation was reinforced by Christian church fathers
held that sex was appropriate only for purposes of procreation.
 No other form of sexual activity has been more frequently discussed, more roundly
condemned, and more universally practiced than masturbation.
nearly all men and three fourths of all women masturbate sometime during their
lives.
males learn to masturbate to orgasm earlier than females and masturbate more
frequently.
when women masturbate, most prefer clitoral stimulation.
women prefer the shaft of the clitoris to the glans because the glans is
hypersensitive to intense stimulation.
Most men masturbate by vigorously stroking the penile shaft and glans.
15

 Masturbation…..
Viewed as sinful act as many religious views
Masturbation is a psychopathological symptom only when it becomes a
compulsion
 It is a symptom of disturbance not because it is sexual, but because it is
compulsive.
It is also symptomatic of sexual problems when it is the only sexual
activity of a person who has an available intimate partner.
16

Physiological Responses
Phase of sexual bhr response cycle:
Phase I, desire;
phase II, excitement;
phase III, orgasm;
phase IV, resolution
The sequence of responses may not occur in a linear
progression, but may overlap and fluctuate. May 24, 2019by Alemu L
17

Phase I: Desire
 Its Appetitive stage
Phase I is a psychological phase distinct from any identified
solely through physiology and reflects motivations, drives
Characterized by sexual fantasies and the conscious desire to
have sexual activity.
Desire may be biologically driven or it may result from a
wish to bond sexually with a particular partner.
18

Phase II: Excitement
This the arousal phase.
Characterized by penile erection in men and vaginal
lubrication in women
Excitement brought on by
 psychological stimulation (fantasy or the presence of a
love object)
19

 physiological stimulation (stroking or kissing), or a
combination of the two.
subjective sense of pleasure and objective signs of
excitement.
The nipple become erect
With continued stimulation, the man's testes increase in
size 50 percent and elevate.
20

The clitoris elevates and retracts behind the symphysis
pubis; hence, it is not easily accessible.
Breast size in the woman increases 25 percent.
Voluntary contractions of large muscle groups occur, rate
of heartbeat and respiration increases, and blood pressure
rises.
Excitement lasts 30 seconds to several minutes.
21

Phase III: Orgasm
 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,
and forceful emission of semen follows.
 In women, orgasm is characterized by 3 to 15 involuntary contractions of
the lower third of the vagina
 Sustained contractions of the uterus, flowing from the fundus downward
to the cervix.
22

 Both men and women have involuntary contractions of the internal and
external anal sphincter.
 Other manifestations include voluntary and involuntary movements of the
large muscle groups, including facial grimacing
 Blood pressure rises 20 to 40 mm (both systolic and diastolic), and the heart
rate increases up to 160 beats per minute.
 Orgasm lasts from 3 to 25 seconds and is associated with a slight clouding of
consciousness
23

Phase IV: Resolution
Resolution 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 cxzed by a subjective sense
of well-being, general relaxation, and muscular relaxation.
24

After orgasm, men have a refractory period that may last
from several minutes to many hours; in this period, they
cannot be stimulated to further orgasm.
The refractory period does not exist in women, who are
capable of multiple and successive orgasms.
25

LOVE AND INTIMACY
Being mentally health could be determined by a person’s ability to function well in
two spheres, work and love.
When involved in an intimate relationship , the person actively strives for the
growth and happiness of the loved person.
Sex frequently acts as a catalyst in forming and maintaining intimate relationships.
The quality of intimacy in a mature sexual relationship is called “active receiving,”
in which a person, while loving, permits himself or herself to beloved.
The value of sexual love is an expansion of self-awareness, the experience of
tenderness, an increase of self-affirmation and pride, and sometimes, at the moment
of orgasm, loss of feeling of separateness.
May 24, 2019
by Alemu L
26

SEX AND THE LAW
o Medicine and the law both assess the impact of sexuality on the individual and
society and determine what is healthy or legal behavior.
o Appropriateness or legality of sexual behavior, however, is not always viewed the
same way by professionals in both disciplines.
o The issues at the interface of sexual science and the law often are emotionally
charged and reflect cultural divisions about acceptable sexual mores.
o They include abortion, pornography, prostitution, sex education, the treatment of
sex offenders, and the right to sexual privacy, among other issues.
o Laws regarding (e.g., criminalization of oral or anal sex by consenting adults, or
the need for parental permission by minors who are requesting an abortion) varies
from place to place and depends on individuals resilience to wards their
conscience and instinct. May 24, 2019
by Alemu L
27

Taking a Sexual History
The development of rapport requires an accepting
atmosphere and a nonjudgmental attitude patients'
sexual values, ideas, and practices
Premarital expectations, mutual physical attraction,
periods of separation, type of contraception used, and the
effect of children on the couple's sexual life are covered
28

The sexual orientation should be ascertained
Review high-risk sexual behavior as transmission HIV
Issue of sexual abuse must be explored
29

Sexual Dysfunctions
30

sexual dysfunctions
The essential features of sexual dysfunctions are an inability to
respond to sexual stimulation, or the experience of pain during the
sexual act.
Dysfunction can be defined by disturbance in the subjective sense of
pleasure or desire usually associated with sex, or by the objective
performance.
Can be lifelong or acquired, generalized or situational.
31

 Sexual dysfunctions can result from
psychological factors
physiological factors,
numerous stressors including prohibitive cultural mores
health and partner issues, and relationship conflicts
If the dysfunction is attributable entirely to a general medical
condition, substance use, or adverse effects of medication, then
sexual dysfunction due to a general medical condition or
substance-induced sexual dysfunction is diagnosed.
32

A number of factors must be considered during the assessment of sexual
dysfunction
1) Partner factors (e.g., partner's sexual problems; partner's health status)
2) Relationship factors (e.g., poor communication; discrepancies in desire for
sexual activity)
3) Individual vulnerability factors (e.g., poor body image; history of sexual or
emotional abuse), psychiatric comorbidity (e.g., depression, anxiety), or
stressors (e.g., job loss, bereavement)
4) Cultural or religious factors (e.g., inhibitions related to prohibitions against
sexual activity or pleasure; attitudes toward sexuality)
5) Medical factors relevant to prognosis, course, or treatment.
33

The dysfunction is expressed as a lack of desire or of pleasure or
as a physiological inability to begin, maintain, or complete
sexual interaction
Frequently associated with other mental disorders, such as
depressive disorders, anxiety disorders, personality disorders,
and schizophrenia
Sexual function can be affected by stress of any kind, by
emotional disorders, and by a lack of sexual knowledge.
34

DSM-5 classified sexual dysfunctions in to tree themes:
1. DESIRE, INTEREST, AND AROUSAL DISORDERS
2. ORGASM DISORDERS
3. SEXUAL PAIN DISORDERS
35

DESIRE, INTEREST, AND AROUSAL DISORDERS
includes
Male Hypoactive sexual desire disorder
Female Sexual Interest/Arousal Disorder
Male Erectile Disorder
36

Male Hypoactive sexual desire disorder
Characterized by a deficiency or lack of sexual fantasies and desire for
sexual activity.
Men for whom this is a lifelong condition, have never experienced
many spontaneous erotic/sexual thoughts.
Prevalence of low desire is greatest at the younger and older ends of the
age spectrum.
Some men may confuse decreased desire with decreased activity
Their erotic thoughts and fantasies are undiminished, but they no longer
act on them due to health issues, unavailability of a partner, or another
sexual dysfunction such as erectile disorder. May 24, 2019by Alemu L
37

 Lack of desire be expressed by
decreased frequency of coitus
perception of the partner as unattractive
overt complaints of lack of desire
Experienced by both men and women
May be used to mask another sexual dysfunction
Upon questioning, the patient is found to have few or no sexual
thoughts or fantasies, or lack of awareness of sexual cues.
38

Hypoactive desire may result due to
low serum testosterone concentrations
chronic stress, anxiety, or depression.
Abstinence from sex for a prolonged period
expression of hostility toward the partner or signal a deteriorating
relationship.
39

Also it depends on adequate
Self-esteem
Previous experiences with sex
The availability partner
Status of relationship
Duration of relationship.
40

 Freud conceptualized sexual aversion as the result of inhibition during the phallic
psychosexual phase/fixation.
 Fixated men at the phallic stage, fear the vagina and believe they will be castrated if
they approach it.
 Because they believe unconsciously as vagina has teeth.
 The need for sexual activity varies among different persons, as well as in the same
person over time.
 A study among couples with stable marriages, reported 8 % having intercourse less
than once a month.
 In another group of couples, one-third reported lack of sexual relations for periods
averaging 8 weeks.
41

DSM V: Male Hypoactive sexual desire disorder
A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies
and desire for sexual activity.
B. Persisted for a minimum duration of ~ 6 months.
C. Cause clinically significant distress
D. Not explained by a nonsexual mental disorder or due to stressors and is not due
to substance/ medication or another medical condition.
 Specify whether:
• Lifelong
• Acquired
• Generalized
• Situational
 Specify current severity:
• Mild
• Moderate
• Severe
42

Female Sexual Interest/Arousal Disorder
Women do not necessarily move step wise from desire to arousal.
Often experience desire occurring simultaneously with, or even
following, beginning feelings of arousal
This is particularly true for women in long-term relationships
Women may experience either/or both inability to feel interest or
arousal
They may often have difficulty achieving orgasm OR experience
pain in addition
43

 Complaints in this dysfunction category present variously as
A decrease or paucity of erotic feelings, thoughts, or fantasies;
A decreased impulse to initiate sex.
A decreased or absent receptivity to partner overtures.
An inability to respond to partner stimulation.
44

Female Sexual Interest/Arousal Disorder con’..
 A complicating factor in this diagnosis is that a subjective sense of arousal is
often poorly correlated with genital lubrication in both normal and
dysfunctional women.
 Therefore, complaints of lack of pleasure are sufficient for this diagnosis even
when vaginal lubrication and congestion are present.
 A woman complaining of lack of arousal may lubricate vaginally, but may not
experience a subjective sense of excitement.
45

Factors such as
life stresses
Aging
Menopause
general health
medication regimen, must be evaluated before making this diagnosis
Relationship problems are particularly relevant to acquired
interest/arousal disorder.
46

DSM V
A. Lack of, or significantly reduced, sexual interest/arousal, as
manifested by at least three of the following:
1. Absent/reduced interest in sexual activity.
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unreceptive
to a partner’s attempts to initiate.
4. Absent/reduced sexual excitement/ pleasure during sexual activity
in almost all or all sexual encounters (in identified situational
contexts or, if generalized, in all contexts). May 24, 2019by Alemu L
47

5. Absent/reduced sexual interest/arousal in response to any
internal or external sexual/ erotic cues (e.g., written, verbal,
visual).
6. Absent/reduced genital or nongenital sensations during sexual
activity in almost all or all sexual encounters (in identified
situational contexts or, if generalized, in all contexts).
48

B. Persisted for a minimum duration of ~ 6 months.
C. Cause clinically significant distress
D. Not explained by a nonsexual mental disorder or due to stressors and is not
due to substance/ medication or another medical condition.
• Lifelong
• Acquired
• Generalized
• Situational
• Mild
• Moderate
• Severe
49

Male Erectile Disorder
50

Erectile Disorder
 Also called erectile dysfunction and impotence
 A man with lifelong male erectile disorder has never obtained an erection
sufficient for vaginal insertion.
 In acquired male erectile disorder, however, the man successfully achieved
vaginal penetration at some time in his sexual life but, later, cannot do so.
 In situational male erectile disorder, the man can have coitus in certain
circumstances but not in others for example, a man may function effectively with
a prostitute but not with his wife.
51

The feelings of powerlessness, and low self-esteem among
men affected more
Other factors:
Feeling of inadequacy or distrust.
Sense of being unloving or unlovable.
Fear, anxiety, anger, or moral prohibition. causes erectile
dysfunction
Episodes of impotence are reinforcing the man becoming
increasingly anxious about his next sexual encounter.
52

Erectile disorder Diagnosis …DSM-5
A. At least one of the three
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. a minimum duration of approximately 6 months.
53

2. ORGASM DISORDERS
May 24, 2019
54
by Alemu L

Orgasmic Disorders includes;
Female orgasmic disorder
Male orgasmic disorder
Premature Ejaculation
May 24, 2019
55
by Alemu L

Defined as recurrent and persistent inhibition of female
orgasm
Manifested by the absence or delay of orgasm after a
normal sexual excitement phase.
Women who can achieve orgasm with non-coital clitoral
stimulation; but cannot experience it during coitus in the
absence of manual clitoral stimulation are not necessarily
categorized as an orgasmic.
May 24, 2019
56
by Alemu L

Lifelong female orgasmic disorder exists when a woman has
never experienced orgasm by any kind of stimulation
Acquired orgasmic dysfunction exists if a woman has
previously experienced at least one orgasm
Lifelong female orgasmic disorder is more common among
unmarried women than among married women
The incidence of orgasmic disorder increases with age.
May 24, 2019
57
by Alemu L

Increased orgasmic disorder in women older than 35 has been
explained on the basis of
 less psychological inhibition,
 greater sexual experience, or both
Orgasmic consistency correlated with marital happiness
Numerous psychological factors are associated with female
sexual inhibition
 fears of impregnation,
 rejection by the sexual partner,
 damage to the vagina;
 hostility toward men; and
 feelings of guilt regarding sexual impulses.
May 24, 2019
58
by Alemu L

Female orgasmic disorder cont’d
Some women match orgasm with loss of control
or with aggressive, destructive, or violent
behavior.
Fear of those impulses may be expressed through
inhibition of excitement or orgasm.
The expression of orgasmic inhibition varies
Others enjoy self-stimulation but cannot reach
orgasm with a partner present.
May 24, 2019
59
by Alemu L

Cultural expectations and societal restrictions on
women are also relevant.
Non-orgasmic women may experience pelvic
complaints as lower abdominal pain, itching, and
vaginal discharge, as well as increased tension,
irritability, and fatigue.
May 24, 2019
60
by Alemu L

Study indicated 46% of women complained of difficulty reaching
orgasm.
Inhibition of arousal and orgasmic problems often occur together.
The overall prevalence of female orgasmic disorder from all causes
is estimated to be 30%.
May 24, 2019
61
by Alemu L

DSM V Female Orgasmic Disorder
A. Presence of either of the following symptoms and 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 delay in, marked infrequency of, or absence of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
 B. Persisted for a minimum duration of ~ 6 months.
 C. Cause clinically significant distress
 D. Not explained by a nonsexual mental disorder or due to stressors and is not due
to substance/ medication or another medical condition.
62

• Mild
• Moderate
• Severe
• Lifelong
• Acquired
• Generalized
• Situational
63

Male Orgasmic Disorder
A man achieves climax during coitus with great difficulty
Lifelong orgasmic disorder: if he has never ejaculated during
coitus.
Acquired: if it develops after previous normal functioning
Inhibited orgasm must be differentiated from retrograde
ejaculation, in which ejaculation occurs but the seminal fluid
passes backward into the bladder.
Retrograde ejaculation can develop after genitourinary surgery
and is also associated with medications that have anticholinergic
adverse effects, such as thioridazine.
May 24, 2019
64
by Alemu L

Male Orgasmic Disorder cont’d
More common among men with obsessive-compulsive disorders
(OCDs)
Male orgasmic disorder may have physiological causes
can occur after surgery of the genitourinary tract, such as
prostatectomy.
Parkinson's disease and other neurological disorders involving
the lumbar or sacral sections of the spinal cord.
antihypertensive drugs, Phenothiazines, and almost all the
antidepressants.
Transient retarded ejaculation may occur with excessive alcohol
intake or with hyperglycemia. May 24, 2019
65
by Alemu L

Male Orgasmic Disorder cont’d
Men with adult attention-deficit disorder are easily
distracted that they cannot focus on the pleasurable
sensations of arousal consistently enough to attain a
degree of excitement necessary for orgasm.
May 24, 2019
66
by Alemu L

Orgasmic Disorder Diagnosis …DSM-5
A. Presence of either of the following symptoms and
experienced on almost all or all occasions of sexual
activity
1. Marked delay in, or absence of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
B. a minimum duration of approximately 6 months.
May 24, 2019
67
by Alemu L

Premature Ejaculation
Achieves orgasm and ejaculates before the wishes to do so.
The diagnosis is made when the man regularly ejaculates before
or immediately after entering the vagina or after minimal sexual
stimulation.
Affected by
Age
novelty of the sexual partner
frequency and duration of coitus.
May 24, 2019
68
by Alemu L

Premature Ejaculation cont’d
More common among college-educated men than among men with
less education
It is thought to be related to their concern for partner satisfaction.
It is estimated 30% of the male population have the dysfunction
Associated with anxiety regarding the sex act.
Other psychological factors include sexual guilt, interpersonal
hypersensitivity, and perfectionism or unrealistic expectations about
sexual performance.
May 24, 2019
69
by Alemu L

Diagnosis …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. at least 6 months
Specify: life long Vs acquired, situational Vs. generalized
May 24, 2019
70
by Alemu L

3. SEXUAL PAIN DISORDERS
May 24, 2019
71
by Alemu L

Genito-Pelvic Pain/Penetration Disorder.
Difficulty having intercourse; genito-pelvic pain; fear of pain or
penetration; and tension of the pelvic floor muscles
Classified as;
Dyspareunia.
Vaginismus.
May 24, 2019
72
by Alemu L

Genito-Pelvic Pain/Penetration Disorder
Dyspareunia.
Recurrent or persistent genital pain occurring before,
during, or after intercourse in either a man or a woman.
In women, the dysfunction is related to and often
coincides with vaginismus.
Repeated episodes of vaginismus may lead to
dyspareunia and vice versa
Dyspareunia should not be diagnosed as such when a
medical basis for the pain is found
May 24, 2019
73
by Alemu L

Dyspareunia cont’d
Surgical procedures on the female genital area result in temporary
dyspareunia
More common in women with a history of rape or childhood sexual
abuse
Painful coitus may result from tense vaginal muscles
May cause the woman to avoid coitus altogether
Dyspareunia can also occur in men, but it is uncommon and usually
associated with a medical condition such as prostatitis, or
gonorrheal or herpetic infections.
May 24, 2019
74
by Alemu L

Vaginismus
Defined as an involuntary and persistent constriction of
the outer one third of the vagina that prevents penile
insertion and intercourse.
Phobic avoidance of penetration is the defining factor
of this syndrome.
The diagnosis is not made if the dysfunction is caused
exclusively by medical or surgical factors
A milder form of the dysfunction, in which some vaginal
tightness makes penile entry difficult, is experienced by
more women on an intermittent or chronic basis.
May 24, 2019
75
by Alemu L

Vaginismus
A woman suffering from vaginismus may consciously
wish to have coitus but unconsciously prevents penile
entrance into her body.
A sexual trauma, such as rape, may result in vaginismus.
Women who have experienced pain with nonsexual
bodily traumas, through accidents or because of illness or
surgery, may become sensitized to the idea of penetration.
May 24, 2019
76
by Alemu L

Treatment of sexual dysfunctions
May 24, 2019
77
by Alemu L

Pharmacotherapy
Nitric oxide enhancers such as sildenafil; used in the
treatment of erectile disorder
Sildenafil augments an erection during sexual
stimulation.
The drug takes effect approximately 1 hour after
ingestion, and its effect can last up to 4 hours.
Sildenafil has no effect in the absence of sexual
stimulation?????
May 24, 2019
78
by Alemu L

Pharmacotherapy cont’d
Common adverse events of sildenafil are headaches,
flushing, and dyspepsia
A more serious visual side effect is the loss of visual
acuity and ischemic optic neuropathy.
Caution in prescribing sildenafil with a recent (6-month)
history of myocardial infarction, stroke, life-threatening
arrhythmia, significant hypotension or hypertension,
cardiac failure, angina
A rare but serious side effect is gangrene of the penis.
If an erection lasts more than 3 hours the man should go
to the emergency room where he can readily be treated.
May 24, 2019
79
by Alemu L

Pharmacotherapy cont’d
Antidepressants: The side effects of SSRIs, which include
delayed orgasm, treats pts with premature ejaculation.
Daily treatment is recommended
Paroxetine (20 to 40 mg) being the most effective,
followed by clomipramine (10 to 50 mg), sertraline (50 to
100 mg), fluoxetine (20 to 40 mg), citalopram (20 to 40
mg), and escitalopram (10 to 20 mg).
May 24, 2019
80
by Alemu L

Hormone Therapy
Androgens increase the sex drive in women and in men with
low testosterone concentrations
Prolonged use of androgens may produce hypertension and
prostatic enlargement.
Testosterone is most effective when given parenterally; Oral
preparations are associated with increased risk of
hepatotoxicity
Gonadotrophin-releasing hormone (GnRH) stimulates the
release of luteinizing hormone, which increases testosterone
secretion in both sexes.
It stimulates desire and increases potency
May 24, 2019
81
by Alemu L

.
Psychotherapy
Exploration of the unconscious conflicts, motivation and
fantasies.
Dual sex therapy
Masters and Johnson
82

.
Couple orientation: The entire marital relationship is treated with
emphasis on sexual functioning.
Sexuality education
Reduction of performance anxiety
Positive attitude change
Improving communication between partners
Taking responsibility for oneself
Behavioral assignments:
Improving life style
Avoid sexual sabotage
83

.
Sensate Focus - behavioral home play assignment
Sense of touch is the most important .
sensual not sexual
Step one
Exclusion of the breasts and the genitalia; ttempts of sexual intercourse is
prohibited at this stage.
Step two:
The same but the prohibition against touching the breasts and the genitalia
is lifted.
An exercise called hand riding
Step three
Breast and genital caressing, with out penetration
84

.
Specific Dysfunctions
In case of PE, an exercise called squeeze technique or the start
stop technique
Hypnotherapy:
 Focuses on anxiety producing symptom
 It is a symptom removal and attitude alteration technique/self
exercise/
Behavior therapy
 Learned maladaptive behavior
 A hierarchy of anxiety provoking situations ranging from least
threatening/e.g.. thought of kissing/to most threatening/
thought of penile penetration-therapist systematically
desensitizes
85

Dual-Sex Therapy
Both individuals are involved in a relationship
The marital relationship as a whole is treated, with emphasis on
sexual functioning
Improved communication in sexual and nonsexual areas is a specific
goal of treatment.
Psychological and physiological aspects of sexual functioning are
discussed with an educational attitude.
Suggestions are followed in the privacy of the couple's home.
May 24, 2019
86
by Alemu L

Dual-Sex Therapy cont’d
Evidence of major underlying psychopathology suggests further
psychiatric evaluation, and participation in the program may be
deferred until the patient seems better able to benefit from it.
Concurrent psychotherapy with dual-sex therapy is sometimes
recommended.
Each patient is interviewed individually early in the course of
treatment.
May 24, 2019
87
by Alemu L

Behavioral Exercises
Couples learn to give and receive bodily pleasure without the
pressure of performance
Beginning exercises usually focus on heightening sensory
awareness to touch, sight, sound, and smell
During these exercises, the couples are given much reinforcement
to lessen anxiety.
They are urged to use fantasies to distract them from obsessive
concerns about performance,
The needs of both the dysfunctional partner and the non-
dysfunctional partner are considered
May 24, 2019
88
by Alemu L

Behavioral Exercises cont’d
Open communication between the partners is urged, and the
expression of mutual needs is encouraged.
Genital stimulation is eventually added to general body stimulation.
The couple is sequentially taught to try various positions for
intercourse
May 24, 2019
89
by Alemu L

Behavioral Exercises cont’d
The specific exercises vary with differing presenting complaints,
and special techniques are used to treat the various dysfunctions.
In cases of vaginismus, for instance, the woman is advised to
dilate her vaginal opening with her fingers or with size-graduated
vaginal dilators as part of the therapy.
May 24, 2019
90
by Alemu L

Thank you !
91

Sexual disorders for psychiatry students

Recommended

Recommended

More Related Content

Similar to Sexual disorders for psychiatry students

Similar to Sexual disorders for psychiatry students (20)

Recently uploaded

Recently uploaded (20)

Sexual disorders for psychiatry students

Editor's Notes