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Psycho sexual disorders-prof. fareed minhas

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  • 1. Prof. Dr. Fareed A. Minhas Head, Institute of Psychiatry Rawalpindi General Hospital Rawalpindi
  • 2. DSM IV ICD 10 Sexual Dysfunction Sexual Dysfunction not due to organic disorders Sexual Desire disorders Lack/loss of desire Sexual arousal disorder Aversion/Lack of enjoyment Orgasm disorders Failure of genital response Sexual pain disorders Orgasmic dysfunction Dysfunction due to medication Premature ejaculation Non-organic pain disorders Paraphilias Excessive sexual drive Disorders of sexual preference Exhibitionism / Fetishism Exhibitionism / Fetishism Frotteurism / Paedophilia Paedophilia / Sadomasochism Sexual Masochism / Sadism Voyeurism / Transvertism Voyeurism / Transvertism Gender Identity Disorders Gender Identity Disorders In children In adolescents and adults
  • 3. SEXUAL DYSFUNCTION  Affecting sexual desire – Low libido  Impaired sexual arousal – Erectile Impotence in men Failure of arousal in women  Affecting orgasm – Premature / Retarded ejaculation Female orgasmic disorder  Sexual pain disorders – Dyspareunia Vaginismus  Sexual dysfunction due to general medical conditions HOMOSEXUALITY In men / In women
  • 4. SEXUAL DEVIATIONS  Variations of the sexual object – Fetishism;Transvestitism Pedophilia; Bestiality; Necrophilia  Variation of the sexual act – Exhibitionism; Voyeurism; Sadism; Masochism; Frotteurism • DISORDERS OF GENDER IDENTITY  Transexualism  Gender disturbance in children
  • 5. 93% of men, 28% of women masturbated by age of 20 37% of men had experienced homosexual orgasm 4% of men had experienced only homosexual orgasm Men show peak of sexual activity in late adolescence Women show peak of sexual activity in early 30’s 75% of Male achieve orgasm within 2 minutes of penetration
  • 6. Erectile impotence 0-1% under 20 years , 6.7% 40-50 years; 7.5% over 70 75% of women achieve orgasm in first year of marriage 11% of boys, 6% of girls had intercourse by age 16; 30% of boys, 16% of girls had intercourse by age 18 40% of married men report some degree of impotence 60% of married women report some degree of orgasmic dysfunction
  • 7. HORMONAL SYSTEM INVOLVED IN THE SEXUAL CYCLE IN FEMALES
  • 8. HORMONAL SYSTEM INVOLVED IN THE SEXUAL CYCLE OF MEN
  • 9. DESIRE AROUSAL PLATEAU ORGASM RESOLUTION Affected by social,personal,cultural, Hypothalamic and hormonal factors Excitement mediated by PNS; genital vasoconstriction leading to erection in male and swelling or lubrication in females Maintenance of arousal state Emission-male only;Ejaculation in male and equivalent in female mediated by SNS With longer refractory period in the male (can be 24 hours if over 60) and very short refractory period in female (allowing for multiple orgasm) Masters & Johnson (1966), Kaplan (1978)
  • 10. ERECTILE IMPOTENCE Inability to sustain an erection adequate for penetration. Most common disorder presenting in males at clinics EJACULATORY IMPOTENCE Inability to ejaculate after adequate erection. Uncommon PREMATURE EJACULATION Ejaculation before, during or immediately after penetration. Usually in young men common ANORGASMIA (frigidity) orgasm achieved rarely or never
  • 11. CHANGING ATTITUDES About 25% of male have no orgasm during intercourse for the first years of marriage. SOME REQUIRE: Stimulation of clitoris and vagina. 1/3 only vaginal stimulation. 10% an-orgasmic ANOTHER STUDY: 20% male rarely orgasmic 50% male sometimes 30% male nearly always
  • 12. VAGINISMUS Involuntary contraction of vaginal introitus in response to attempts at penetration Reasons:  Fear about penetration  Scarring after episiotomy  Guilt of relationship • DYSPAREUNIA Pain on intercourse Causes: Impaired lubrication Scars or other painful lesions, Muscle spasm   Pelvic pathology(Endometriosis ovarian cyst tumors pelvic infection)
  • 13. FACTORS COMMON TO ALL DYSFUNCTIONS Poor general relationship with the partner Low sexual drive Ignorance about the sexual technique Anxiety about the sexual performance Physical illnesses / Drugs (detailed in slides that follow) PARTICULAR CONDITIONS Male erectile disorder : Primary / Secondary / Abnormal vascular supply of local region Female orgasmic disorder : normal variations / combination of above factors
  • 14. MEDICAL AND SURGICAL CONDITIONS COMMONLY ASSOCIATED WITH SEXUAL DYSFUNCTIONS MEDICAL Endocrine Diabetes, hyperthyroidism, myxoedema, Addisons disease, hyperprolactinemia Gynaecological Vaginitis, endometriosis, pelvic infections Cardiovascular Angina pectoris, previous myocardial infarction Respiratory Asthma, Obstructive airways disease Arthritic Arthritis from any cause Renal Renal failure with or without dialysis Neurological Pelvic autonomic neuropathy, spinal cord lesions stroke SURGICAL Mastectomy; Colostomy; ileostomy; oophorectomy Episiotomy; operations for prolapse Amputation
  • 15. DRUGS MOST COMMONLY ASSOCIATED WITH SEXUAL DYSFUNCTION Alcohol Anti Hypertensives: Guanethidine, beta adrenoceptor antagonists, methyl dopa. Anti depressants: TCA, MAOI inhibitors. Anxiolytics and Hypnotics: Benzodiaziprines, Barbiturates Anti psychotics: Thioridazine. Anti Inflammatory Drugs: Indomethacin. Anti Cholinergic Drugs: Probanthine. Diuretics: Bendrofluazide. Hormones: Steroids, possibly oral contraceptives
  • 16. IMPORTANT POINTS IN THE PHYSICAL EXAMINATION OF MEN WITH SEXUAL DYSFUNCTION General Examination (directed especially to evidence of Diabetes Mellitis,thyroid or adrenal disorder) Hair Distribution Gynaecomastia Blood pressure and peripheral pulses Ocular Fundi / Reflexes / Peripheral Sensation Genital Examination Penis : congenital anomalies;foreskin;pulses;tenderness; plaques;infections;urethral discharge Testicles : size; symmetry; texture; sensation
  • 17. MASTERS & JOHNSON (1970)  Partners are treated together:  Helped to communicate better.  They are taught the anatomy and physiology of sexual intercourse.  Given graded series of “Sexual Tasks” sensate focus: Mutual Masturbation. Prohibit penetration.Prohibit ‘spectator role’  Intensive treatment: Everyday × 3 weeks  Male and female therapist SPECIAL TECHNIQUES: DYNAMIC PSYCHOTHERAPY Squeeze technique Start stop technique Relaxation training(Vaginismus) Use of vibrator (Anorgasmia) Masturbation  
  • 18. HAWTHORN 1980: Best results obtained with vaginismus and premature ejaculation RESULTS GOOD: evaluated HORMONES:   - Short duration of illness. No serious marital problem. No Psychiatric problem. No adequate controlled trials: Psychotherapy not been in controlled trials. Testosterone in hypogonadism. No evidence that testosterone improves impotence unless gross endocrine disorder Bromocryptine has been used for impotence Generally no convincing evidence
  • 19. MASTERS & JOHNSON (1970) Primary Impotence: 50% cure Secondary Impotence: 70 – 80% cure Pre-mature ejaculation: 100% cure Female dysfunction: 80% cure Study was carried out on erectile impotence by Ansari (1976) 3 groups of patients presented with different prognoses
  • 20. Group 1 Group 2 Group 3 Acute onset Short duration. Insidious onset Insidious onset chronic relationship With no problems discoverable Precipitant present. Often decrease sexual Precipitants response in partner (acute or chronic) Younger age(av 30) often history of Often unmarried. older age: av. 45 low sex drive older age: av: 45 Good Prognosis With treatment. Unlikely to relapse. Good Result & Treatment, but likely to relapse. Poor Prognosis. Unlikely to respond to treatment.
  • 21. For centuries, variations in sexual act were regarded as offences against the laws of religion rather than disorders that doctors should study and treat Nowadays the concept of sexual deviance has 3 aspects: SOCIAL PERSONAL SUFFERING HARM TO OTHERS
  • 22. The term denotes erotic thoughts and feelings towards a person of the same sex, whether or not they are associated with overt sexual behavior  THE CONTINUUM - EXCLUSIVELY EXCLUSIVELY HOMOSEXUAL HETEROSEXUAL
  • 23. Behavior includes: Oral-genital contact mutual masturbation, less often anal intercourse.Partners usually change voles. (Passive vs active) Relationship does not last long Some exclusively homosexual male experience strong feelings of identity towards other homosexuals and adopt the corresponding social behavior e.g. club, bars, dress in effeminate style of life, and female mannerisms   Homosexual men vary in personality as much as do other male   Many homosexuals male live as happily as those who are heterosexual. For others homosexuality leads to difficulties with change with increasing age. Middle age → loneliness, isolation, and depression particularly if male has not previously established stable relationship, this leads to relationships:homosexual prostitutes,prepubertal children.
  • 24. Behavior: Mutual masturbation, oral-genital contact, caressing and breast stimulation.Small university: full body contact with genital friction or pressure, vibrator or artificial penis Active and passive roles are interchanged   Social behavior of lesbians is usually unremarkable   All kinds of personalities are represented among female lesbians. Most lesbians engage in heterosexual relationships at some time even though they obtain less satisfaction.   Legal aspects of homosexuality   No laws specifically concerning homosexual behavior between female   England/Wales: ↑ 21, in private, between consenting males is not an offence
  • 25. Various unproven theories. Most refer to male.    GENETICS: MZ twins have higher concordance than DZ    PRENATAL FACTORS: Hormonal influences e.g. androgens, at critical periods of brain development. ‘Effeminate’ boys are more likely to become homosexual    ENVIRONMENTAL FACTORS: Absent or unsatisfactory father and close binding relationship with mother said to be important
  • 26.  Shy and sexually in experienced young men who fear that they may be homosexual but in fact are not Young male who have realized that they are predominantly homosexual; bewildered about the implications for their lives Men who have bisexual inclinations; want to discuss ways of arranging their lives appropriately Established homosexual who becomes depressed or anxious for personal/social difficulties arising from sexual relationship Doctors principal role is to help the patient to clarify his thoughts. **   Occasionally: Behavior modification of patients homosexual impulses and behavior.   ?? Psychoanalysis and psychotherapy: without convincing evidence.