Sexual response cycle2 Desire Excitement Plateau Orgasm Resolution May occur at one or more of these phases
Sexual changes with aging3 The desire for sexual activity does not usually change as people age. MEN: usually require more direct stimulation of genitals and more time to achieve orgasm. The intensity of ejaculation usually decreases, and the length of refractory period increases. WOMEN: After menopause, women experience vaginal dryness and thinning due to decreased levels of estrogen. These conditions can be treated with hormone replacement therapy or vaginal creams.
DDx of sexual dysfunction4 General medical conditions: Examples include history of atherosclerosis (causing erectile dysfunction from vascular occlusion), diabetes (causing erectile dysfunction from vascular changes and peripheral neuropathy), and pelvic adhesions (causing dyspareunia in women). Abnormal levels of gonadal hormones: Estrogen- decreased levels after menopause cause vaginal dryness and thinning in women (without affecting desire). Testosterone- promotes libido (desire) in both men and women. Progesterone- inhibits libido in both men and women by blocking androgen receptors; found in oral contraceptives, hormone replacement therapy, and treatments for prostate cancer.
CONt…5 . : 3 Medication side effects antihypertensives, anticholinergics, antidepressants (especially selective serotonin reuptake inhibitors [SSRIs]), and antipsychotics (block dopamine) may contribute to sexual dysfunction. 4. Substance abuse: Alcohol and marijuana enhance sexual desire by suppressing inhibitions. (However, long-term alcohol use decreases sexual desire.) Cocaine and amphetamines enhance libido by stimulating dopamine receptors. Narcotics inhibit libido. 5. Presence of a sexual disorder . 6. Depression.
SEXUAL DISORDERS6 They all share the following DSM-IV criteria: The disorder causes marked distress or interpersonal difficulty. The dysfunction is not caused by substance use or a general medical condition. The most common sexual disorders in women are sexual desire disorder and orgasmic disorder. The most common disorders in men are secondary erectile disorder and premature ejaculation. Psychological causes of sexual disorders include: Interpersonal problems with sexual partner Guilt about sexual activity (often in persons with religious or puritanical upbringing) Fears (pregnancy, rejection, loss of control, etc.)
Disorders of desire7 Hypoactive sexual desire disorder :absence or deficiency of sexual desire or fantasies (occurs in up to 20% of general population and is more common in women) Sexual aversion disorder: avoidance of genital contact with a sexual partner.
Disorders of Arousal (Excitement and Plateau)8 Stress, fear, fatigue, anxiety, and feelings of guilt may contribute to both erectile disorder in men and sexual arousal disorder in women. Male erectile disorder—inability to attain an erection. May be primary (never had one) or secondary (acquired after previous ability to maintain erections). Secondary erectile disorder is common and occurs in 10 to 20% of men. Female sexual arousal disorder—inability to maintain lubrication until completion of sex act (high prevalence—up to 33% of women)
Disorders of Orgasm9 Both male and female orgasmic disorders may be either primary (never achieved orgasm) or secondary (acquired). Causes may include relationship problems, guilt, stress, and so on. Female orgasmic disorder: Inability to have an orgasm after a normal excitement phase. The estimated prevalence in women is 30%. Male orgasmic disorder: Achieves orgasm with great difficulty, if at all; much lower incidence than impotence or premature ejaculation. Premature ejaculation: Ejaculation earlier than desired time (before or immediately upon entering the vagina). High prevalence—up to 35% of all male sexual disorders; may be caused by fears, guilt, or performance anxiety.
Sexual Pain Disorders10 Dyspareunia: Genital pain before, during, or after sexual intercourse; much higher incidence in women than men; often associated with vaginismus. Vaginismus: Involuntary muscle contraction of the outer third of the vagina during insertion of penis or object (such as speculum or tampon); increased incidence in higher socioeconomic groups and in women of strict religious upbringing.
TREATMENT OF SEXUAL DISORDERS11 Dual Sex Therapy Behavior Therapy Hypnosis Group Therapy Analytically Oriented Psychotherapy
Specific techniques for various dysfunctions12 Sexual desire disorder: Testosterone (if levels are low). Erectile disorder: Yohimbine, sildenafil (Viagra), self-injection of vasoactive substances (such as alprostadil), vacuum pumps, constrictive rings, prosthetic surgery (last resort). Female sexual arousal disorder: Release of clitoral adhesions (if necessary). Male orgasmic disorder: Gradual progression from extravaginal ejaculation (via masturbation) to intravaginal. Female orgasmic disorder: Masturbation (sometimes with vibrator).
CONt…13 Premature ejaculation: The squeeze technique is used to increase the threshold of excitability. When the man has been excited to near ejaculation, he or his sexual partner is instructed to squeeze the glans of his penis in order to prevent ejaculation. Gradually, he gains awareness about his sexual sensations and learns to achieve greater ejaculatory control. The stop–start technique involves cessation of all penile stimulation when the man is near ejaculation. This technique functions in the same manner as the squeeze technique. Pharmacotherapy: Side effects of drugs including SSRIs and tricyclics may prolong sexual response.
CONt…14 Dyspareunia: Gradual desensitization to achieve intercourse, starting with muscle relaxation techniques, progressing to erotic massage, and finally achieving sexual intercourse. Vaginismus: Women may obtain some relief by dilating their vaginas regularly with their fingers or a dilator.
PARAPHILIAS15 Paraphilias are sexual disorders characterized by engagement in unusual sexual activities (and/or preoccupation with unusual sexual urges or fantasies) for at least 6 months that cause impairment in daily functioning. Paraphilic fantasies alone are not considered disorders unless they are intense, recurrent, and interfere with daily life; occasional fantasies are considered normal components of sexuality (even if unusual). Only a small percentage of people suffer from paraphilias. Most paraphilias occur only in men, but sadism, masochism, and pedophilia may also occur in women. The most common paraphilias are pedophilia, voyeurism, and exhibitionism.
Examples of Paraphilias16 Pedophilia: Sexual gratification from fantasies or behaviors involving sexual acts with children (most common paraphilia). Voyeurism: Watching unsuspecting nude individuals (often with binoculars) in order to obtain sexual pleasure. Exhibitionism: Exposure of one’s genitals to strangers. Fetishism: Sexual preference for inanimate objects (e.g., shoes or pantyhose). Transvestic fetishism: Sexual gratification in men (usually heterosexual) from wearing women’s clothing (especially underwear). Frotteurism: Sexual pleasure in men from rubbing their genitals against unsuspecting women; usually occurs in a crowded area (such as subway). Masochism: Sexual excitement from being humiliated or beaten. Sadism: Sexual excitement from hurting or humiliating another. Necrophilia: Sexual pleasure from engaging in sexual activity with dead people. Telephone scatologia: Sexual excitement from calling unsuspecting.
COURSE AND PROGNOSIS17 Poor prognostic factors are early age of onset, comorbid substance abuse, high frequency of behavior, and referral by law enforcement agencies (after arrest). Good prognostic factors are self-referral for treatment, sense of guilt associated with the behavior, and history of otherwise normal sexual activity in addition to the paraphilia.
TREATMENT18 Insight-oriented psychotherapy: Most common method. Patients gain insight into the stimuli that cause them to act as they do. Behavior therapy: Aversive conditioning used to disrupt the learned abnormal behavior by coupling the impulse with an unpleasant stimulus such as an electric shock. Pharmacologic therapy: Antiandrogens have been used to treat hypersexual paraphilias in men.
GENDER IDENTITY DISORDER19 Gender identity disorder is commonly referred to as transsexuality. People with this disorder have the subjective feeling that they were born the wrong sex. They may dress as the opposite sex, take sex hormones, or undergo sex change operations. Gender identity disorder is more common in men than women. It is associated with an increased incidence of major depression, anxiety disorders, and suicide.
HOMOSEXUALITY20 Homosexuality is a sexual or romantic desire for people of the same sex. It is a normal variant of sexual orientation. It occurs in 3 to 10% of men and 1 to 5% of women. The etiology of homosexuality is unknown, but genetic or prenatal factors may play a role. Distress about one’s sexual orientation is considered a dysfunction that should be treated with individual psychotherapy and/or group therapy.