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Psychiatry 5th year, 5th lecture (Dr. Saman Anwar)


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The lecture has been given on Apr. 5th, 2011 by Dr. Saman Anwar.

Published in: Health & Medicine

Psychiatry 5th year, 5th lecture (Dr. Saman Anwar)

  1. 1. Sexual and gender identity disorders<br />Dr.Saman Anwar<br />M.B.Ch.B, F.I.B.M.S(PSYCH)<br />
  2. 2. What Is “Normal” vs. “Abnormal” Sexual Behavior?<br />Cultural considerations<br />Gender differences in sexual behavior and attitudes .<br />Age<br />Individual ability and difference and preference.<br />Life stress, education, love,……etc.<br />NO CUT LINE BETWEEN THE TWO!!!!!!!!<br />
  3. 3. Sexual Response Cycle<br />Desire - inc. fantasies<br />Excitement - subjective pleasure, physiological changes.<br />**Plateau: brief pleasurable period of time before orgasm.**<br />Orgasm - peaking of pleasure, ejaculation or vaginal wall contractions<br />Resolution - differs for sexes, refractory period<br />Sexual Dysfunctions at any of first 3 <br />
  5. 5. Common sexual myths<br />Men should not express their emotions.<br />All physical contact must lead to sex.<br />Good sex leads to a wild orgasm.<br />Sex = intercourse.<br />The man should be the sexual leader.<br />Women should not initiate sex.<br />Men feel like sex all the time.<br />Women should always have sex when her partner makes sexual approaches.<br />Sex is something we instinctively know about.<br />Respectable people should not enjoy sex too much and certainly never masturbate.<br />All other couples have (great)sex, several times a week, have an orgasm every time, and always orgasm simultaneously.<br />If sex is not good, there is something wrong with the relationship.<br />
  6. 6. Sexual Dysfunctions: An Overview<br />Sexual Dysfunctions <br />Affect desire, arousal, and/or orgasm<br />Pain associated with sex can lead to additional dysfunction<br />Males and Females <br />Experience parallel versions of most sexual dysfunctions<br />Affects about 43% of all females and 31% of males<br />Most prevalent class of disorder in the United States<br />Classification of Sexual Dysfunctions<br />Lifelong vs. acquired<br />Generalized vs. specific<br />Psychological factors alone<br />Psychological factors combined with medical conditions<br />
  7. 7. Sexual Desire Disorders<br />Hypoactive Sexual Desire Disorder<br />Little or no interest in any type of sexual activity<br />Masturbation, sexual fantasies, and intercourse are rare <br />Accounts for half of all complaints at sexuality clinics<br />Affects 22% of women and 5% of men<br />Sexual Aversion Disorder<br />Little interest in sex <br />Physical / sexual contact – Extreme fear, panic, disgust<br />10% of males report panic attacks during sexual activity<br />
  8. 8. Excessive sexual desire<br />Occasionally increased sexual drive may occur, presenting as a problem for individuals, partners (on whom (unreasonable)demands are made), or careers (when sexual disinhibition occurs). Referred to as nymphomania (women) or satyriasis (men). Usually occurs in late teenage/early adulthood, secondary to a mood disorder (e.g. mania), in the early stages of dementia, associated with learning disability, secondary to brain injury, or as a side-effect of some drugs.<br />Management Treatment should address any primary problem, general relationship issues. When the problem is persistent, specialist referral may be appropriate (for cognitive, behavioural, or, rarely, pharmacological therapy).<br />
  9. 9. Sexual Arousal Disorders<br />Male Erectile Disorder(IMPOTENCE)<br />Difficulty achieving and maintaining an erection.<br />may be secondary to alcohol, diabetes.<br />Female Sexual Arousal Disorder<br />Difficulty achieving and maintaining adequate lubrication<br />Associated Features of Sexual Arousal Disorders<br />Problem is arousal, not desire<br />Affects about 5% of males, 14% of females<br />Males are more troubled by the problem than females<br />Erectile problems are the main reason males seek help <br />
  10. 10. Orgasm Disorders<br />Inhibited Orgasm: Female and Male Orgasmic Disorder<br />Have adequate desire and arousal<br />Unable to achieve orgasm <br />Rare condition in adult males<br />Most common complaint of adult females<br />25% of adult females report difficulty reaching orgasm<br />Anxiety based?<br />Retarded Ejaculation - usually no orgasm w/ partner, only masturbation.<br />Premature Ejaculation<br />Ejaculation before the man or partner wishes it to<br />21% of all adult males meet diagnostic criteria<br />Most prevalent sexual dysfunction in adult males<br />Common in younger, inexperienced males<br />Problem declines with age<br />
  11. 11. Sexual Pain Disorders<br />Defining Feature<br />Marked pain during intercourse<br />Dyspareunia<br />Extreme pain during intercourse<br />Adequate sexual desire, arousal, and ability to attain orgasm<br />Must rule out medical reasons for pain<br />Affects 1% to 5% of men and about 10% to 15% of women.<br />Vaginismus - involuntary contraction of muscles of outer third of vagina (5-17% of women)<br /> Related to sexual abuse?<br />
  12. 12. Management<br />Exclude physical causes of pain (e.g. infection, tender episiotomy scar, endometriosis, ovarian cyst).<br />Provide information about ensuring adequate arousal, variation of intercourse positions to avoid (deep) penetration.<br />Relaxation techniques (including Kegel's exercises) and (positive self-talk)may help reduce anxiety and ensure the woman feels (in control).<br />Where deep pain is experienced after intercourse, this may be due to pelvic congestion syndrome (with symptoms similar to pre-menstrual syndrome) caused by accumulation of blood during arousal without occurrence of orgasm. Achieving orgasm (by intercourse, masturbation, or use of a vibrator) may help to alleviate this congestion.<br />For complex cases, with vague or intermittent problems, associated secondary sexual or psychiatric problems, or when initial treatment is unsuccessful, referral to a specialist is indicated.<br />
  13. 13. Causes of Sexual Dysfunctions<br />Biological Contributions <br />Physical disease and medical illness<br />Prescription medications<br />Use and abuse of alcohol and other drugs<br />Psychological Contributions<br />The role of “anxiety” vs. “distraction”<br />The nature and components of performance anxiety<br />Psychological profiles associated with sexual dysfunction <br />Social and Cultural Contributions<br />Negative scripts about sexuality<br />Erotophobia – Learned negative attitudes about sexuality <br />Negative or traumatic sexual experiences <br />Poor interpersonal relationships, lack of communication<br />
  14. 14. Medical Treatment of Sexual Dysfunction<br />Erectile Dysfunction<br />Viagra – Is it really the wonder drug?<br />Injection of vasodilating drugs into the penis<br />Penile prosthesis or implants<br />Vascular surgery<br />Vacuum device therapy<br />Few Medical Procedures for Female Sexual Dysfunction<br />Sex hormones: testosterone?!<br />
  15. 15. Paraphilias<br />Recurrent, intense sexually arousing fantasies, urges, or behaviors involving nonhumans, suffering of self or partner, children. (For some these are necessary for erotic arousal & always inc. in sexual activity; for other these occur episodically.)<br />Main Types of Paraphilias<br />Fetishism<br />Voyeurism<br />Exhibitionism<br />Transvestic fetishism<br />Sexual sadism and masochism<br />Pedophilia <br />
  16. 16. Fetishism<br />Sexual attraction – Nonliving objects<br />Objects can be inanimate and/or tactile<br />Examples include rubber, hair, shoes, underwears, <br />Usually many objects of fetishistic arousal, fantasy, urges<br />Voyeurism<br />Observing an unsuspecting individual undressing or naked<br />Risk associated with “peeping” is necessary for arousal <br />
  17. 17. Exhibitionism<br /> exposing genitals to (unsuspecting) stranger(s), most common sex crime in U.S., rare outside, involves shock & risk, often distant from victim, needs to display masculinity w/o having to perform. Element of thrill and risk are necessary for sexual arousal.<br />Transvestic Fetishism<br />Sexual arousal with the act of cross-dressing<br />Males may show highly masculine compensatory behaviors<br />Most do not show compensatory behaviors<br />Many are married and the behavior is known to spouse.<br />Frotteurism<br /> rubbing against nonconsenter( in tram way, bus, lines, crowd places). More common in young adults and could occur in females.<br />
  18. 18. Sexual Sadism and Sexual Masochism<br />Sexual Sadism<br />Inflicting pain or humiliation to attain sexual gratification<br />Sexual Masochism<br />Suffer pain or humiliation to attain sexual gratification<br />Relation Between Sadism and Rape<br />Some rapists are sadists<br />Most rapists do not show paraphilic patterns of arousal<br />Sexual arousal to violent sexual and non-sexual material<br />
  19. 19. Pedophilia<br />Pedophiles – Sexual attraction to young children <br />Incest – Sexual attraction to one’s own children<br />Victims are typically children or young adolescents<br />Pedophilia is rare, but not unheard of, in females<br />Associated Features<br />Most pedophiles and incest perpetrators are male<br />Incestuous males may be aroused to adult women<br />Pedophiles are not aroused by adult women<br />Most rationalize the behavior<br />Engage in other moral compensatory behavior (church) <br />
  20. 20. Pedophilia: Medical Treatment<br />Medications: The Equivalent of Chemical Castration<br />Often used for dangerous sexual offenders <br />Types of Available Medications<br />Cyproterone acetate – Anti-androgen, reduces testosterone, sexual urges and fantasy<br />Medroxyprogesterone acetate – Depo-provera, also reduces testosterone<br />Triptoretin – A newer more effective drug that inhibits gonadtropin secretion<br />Efficacy of Medication Treatments<br />Drugs greatly reduce sexual desire, fantasy, arousal<br />Relapse rates are high with medication discontinuation<br />
  21. 21. Paraphilias: Causes and Assessment<br />Associated with sexual and social problems and deficits <br />Inappropriate arousal / fantasy learned early in life <br />High sex drive plus suppression of urges / drive<br />Psychophysiological Assessment of Paraphilias<br />Deviant patterns of sexual arousal<br />Desired sexual arousal to adult content<br />Social skills and the ability to form relationships<br />
  22. 22. Gender identity disorder<br />
  23. 23. Strong, persistent identification w/ other sex<br />Persistent discomfort w/ sex, inappropriateness in gender role.<br />Person feels trapped in the body of the wrong sex<br />Assume identity of the desired sex<br />Male to female or female to male.<br />The goal is not sexual<br />Causes are Unclear<br />Gender identity develops early – 18 and 36 months/age <br />As child<br />Cross dressing<br />Cross sex roles<br />Played w/ other sex<br />Insisting is other sex<br />
  24. 24. Sex-Reassignment Surgery<br />Who is a candidate? – Basic prerequisites before surgery <br />75% report satisfaction with new identity<br />Adjustment is better for Female-to-male conversions .<br />It is very expensive, and takes years of preparation and<br />maintenance, both biological and psychological.<br />Psychosocial Treatment of Gender Identity Disorder<br />Realign psychological gender with biological sex<br />Few Large Scale Studies.<br />Male to female transgendered people cannot bear children, and can have prostate cancer and other ‘male’ problems. <br />However, transgendered people can have successful intimate and sexual relationships, they do have orgasms following gender reassignment.<br />Medical treatment<br />
  25. 25. Sexual orientation<br />Heterosexual<br />Homosexual<br />Bisexual<br />Not in DSM-IV<br />
  26. 26. A portion of all sexual disorders can be prevented through education alone, but because our society generally shies away from providing such education, people end up with problems in sexual functioning. <br />Additionally, we assume that sexual activity is ‘natural’ and that no education is necessary. This is not true, we all have to learn part of what successful sexual encounters entail.<br />
  27. 27. Thank you<br />