2. Sexual response cycle
May occur at one or more of these phases
3. Sexual changes with aging
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.
4. DDx of sexual dysfunction
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
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.
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. SEXUAL DISORDERS
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
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
Interpersonal problems with sexual partner
Guilt about sexual activity (often in persons with religious or puritanical
Fears (pregnancy, rejection, loss of control, etc.)
7. Disorders of desire
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
8. Disorders of Arousal (Excitement and
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)
9. Disorders of Orgasm
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
10. Sexual Pain Disorders
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
11. TREATMENT OF SEXUAL DISORDERS
Dual Sex Therapy
12. Specific techniques for various dysfunctions
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).
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.
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.
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.
16. Examples of Paraphilias
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
Telephone scatologia: Sexual excitement from calling unsuspecting.
17. COURSE AND PROGNOSIS
Poor prognostic factors are early age of onset, comorbid substance abuse, high
frequency of behavior, and referral by law enforcement agencies (after
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.
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
Pharmacologic therapy: Antiandrogens have been
used to treat hypersexual paraphilias in men.
19. GENDER IDENTITY DISORDER
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.
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.