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SEXUAL DYSFUNCTIONS
Seven major categories of sexual dysfunction are listed in DSM-IV:
(1) sexual desire disorders,
(2) sexual arousal disorders,
(3) orgasmic disorders,
(4) sexual pain disorders,
(5) sexual dysfunction due to a general medical condition,
(6) substance-induced sexual dysfunction, and
(7) sexual dysfunction not otherwise specified.
Characterize by:1. The subject is unable to participate in a sexual relationship as he or she would
wish.
2. The dysfunction occurs frequently, but may be absent on some occasions.
3. The dysfunction has been present for at least 6 months.
4. The dysfunction is not entirely attributable to any of the other mental and
behavioral disorders, physical disorders (such as endocrine disorder), or drug
treatment.
PHYSIOLOGICAL RESPONSES
Phase I: Desire
Phase I: is distinct from any identified physiology and It is characterized by
sexual fantasies and the desire to have sexual activity.
Dysfunctions: e.g. Hypoactive sexual desire; substance-induced sexual
dysfunction with impaired desire
Phase II: Excitement
Phase II is brought on by psychological stimulation (fantasy or the presence of a
love object), physiological stimulation (stroking or kissing), or a combination of
the two. It consists of a subjective sense of pleasure. The excitement phase is
characterized by penile tumescence leading to erection in the man and vaginal
lubrication in the woman. The nipples of both sexes become erect, although
nipple erection is more common in women than in men.
The woman's clitoris becomes hard and turgid, and her labia minora become
thicker as a result of venous engorgement. Initial excitement may last several
minutes to several hours. With continued stimulation, the man's testes increase in
size 50 percent and elevate. The woman's vaginal barrel shows a characteristic
constriction along the outer third known as the orgasmic platform. The clitoris
elevates and retracts behind the symphysis pubis; hence it is not easily accessible.
However, stimulation of the area causes traction on the labia minora and the
prepuce, and there is intrapreputial movement of the clitoral shaft.
Breast size in the woman increases 25 percent. Continued engorgement of the
penis and vagina produces specific color changes, particularly in the labia
minora, which become bright or deep red. Voluntary contractions of large muscle
groups occur, rate of heartbeat and respiration increases, and blood pressure rises.
Heightened excitement lasts 30 seconds to several minutes.
Dysfunctions:
Female sexual arousal disorder; male erectile disorder (may also occur in stages 3
and 4); male erectile disorder due to a general medical condition; dyspareunia
due to a general medical condition (male or female); substance-induced sexual
dysfunction with impaired arousal
Phase III: Orgasm
Phase III 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.
Forceful emission of semen follows. The male orgasm is also associated with
four to five rhythmic spasms of the prostate, seminal vesicles, vas, and urethra. In
the woman orgasm is characterized by 3 to 15 involuntary contractions of the
lower third of the vagina and by strong, sustained contractions of the uterus,
flowing from the fundus downward to the cervix. Both men and women have
involuntary contractions of the internal and external sphincter. Those and the
other contractions during orgasm occur at 0.8-second intervals. Other
manifestations include voluntary and involuntary movements of the large muscle
groups, including facial grimacing and carpopedal spasm.
Blood pressure rises 20 to 40 mm (both systolic and diastolic), and the heart rate
increases up to 160 beats a minute. Orgasm lasts from 3 to 25 seconds and is
associated with a slight clouding of consciousness.
Dysfunctions:
Female orgasmic disorder; male orgasmic disorder; premature ejaculation; other
sexual dysfunction due to a general medical condition (male or female);
substance-induced sexual dysfunction with impaired orgasm
Phase IV: Resolution
Resolution consists of the disgorgement of blood from the genitalia
(detumescence), which 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
characterized by a subjective sense of well-being, general relaxation, and
muscular relaxation. After orgasm men have a refractory period that may last
from several minutes to many hours; in that period they cannot be stimulated to
further orgasm. The refractory period does not exist in women, who are capable
of multiple and successive orgasms.
Dysfunctions:
Postcoital dysphoria; postcoital headache
Sexual Dysfunction Not Correlated With Phases of the Sexual Response Cycle:
Vaginismus (female) , Dyspareunia (female and male)
The most common sexual problems are:
1. erectile dysfunction (males)
2. premature ejaculation (males)
3. vaginismus (females)
4. low sexual desire (females, males)
5. inhibited female orgasm
Characteristics of the DSM-IV Sexual Dysfunctions
Disorder
Characteristics
Hypoactive
Decreased interest in sexual activity
sexual desire
disorder
Sexual
Aversion to and avoidance of sexual activity
aversion
disorder
Female
Inability to maintain vaginal lubrication until the sex act is completed,
sexual
despite adequate physical stimulation (reported in as many as
arousal
20% of women)
disorder
Male erectile Lifelong or primary (rare): has never had an erection sufficient for
disorder
penetration Acquired or secondary (the most common male sexual
(commonly
disorder): is currently unable to maintain erections despite normal
called
erections in the past Situational (common): has difficulty maintaining
"impotence") erections in some sexual situations, but not in others
Orgasmic
disorder
(male and
female)
Premature
ejaculation
Vaginismus
Dyspareunia
Lifelong: has never had an orgasm Acquired: is currently unable to
achieve orgasm despite adequate genital stimulation and normal
orgasms in the past Reported more often in women than in men
Ejaculation before the man would like it to occur Plateau phase of the
sexual response cycle is short or absent Is usually accompanied by
anxiety Is the second most common male sexual disorder
Painful spasms occur in the outer third of the vagina, which make
intercourse or pelvic examination difficult
Persistent pain occurs in association with sexual intercourse without
pelvic pathology (functional dyspareunia) Can also be caused by pelvic
pathology, e.g., pelvic inflammatory disease (PID) caused by
chlamydiosis (most common) or gonorrhea (most serious)
Occurs much more commonly in women; can occur in men
Assessment of a psychosexual problem:
+define the problem
+ Assess sexual history:
+ Sex atmosphere (privacy, foreplay…)
+
+ Physical diseases e.g. diabetes mellitus, hypertension…
ERECTILE DISORDER (IMPOTENCE)
coitus.
s, arterioscleresis, drugs, alcohol.
* Presence of morning erection suggests a psychological cause particularly in an
anxious person who is sensitive to issues related to sex.
nconsummated marriage and divorce.
Management includes:
problems.
importance of privacy and foreplay.
Improving the couple communication (increasing understanding of the wishes
and feelings of the other partner).
Behaviour techniques: gradually reducing performance anxiety and increasing
sensual sexual feelings
al injection of prostaglandin El
(smooth muscle relaxant), sildenafil (viagra) and vacuum devices.
Behavioral treatment techniques
1-In sensate-focus exercises (used to treat sexual desire, arousal, and orgasmic
disorders), the individual's awareness of touch, sight, smell, and sound stimuli are
increased during sexual activity, and psychological pressure to achieve an
erection or orgasm is decreased.
2-In the squeeze technique, which is used to treat premature e jaculation, the
man is taught to identify the sensation that occurs just before the emission of
semen. At this moment, the man asks his partner to exert pressure on the
coronal ridge of the glans on both sides of the penis until the erection subsides,
thereby delaying ejaculation.
3-Relaxation techniques, hypnosis, and systematic desensitization used to
reduce anxiety associated with sexual performance.
4-Masturbation may be recommended to help the person learn what stimuli are
most effective for achieving arousal and orgasm.
Medical and surgical treatment
1-Because they delay orgasm, SSRIs a. (e.g., fluoxetine) are used to treat
premature ejaculation.
2-Systemic administration of opioid antagonists (e.g., naltrexone) and
vasodilators (e.g., yohimbine) have been used to treat erectile disorder.
3-In erectile disorder, sildenafil citrate (Viagra) and related agents work by
blocking an enzyme (phosphodiesterase-5) that destroys cyclic guanosine
monophosphate (cGMP), a vasodilator secreted in the penis with sexual
stimulation. Thus, degradation of cGMP is slowed and the erection persists. Side
effects include blue vision, and it is contraindicated in men who take nitrates.
Newer PDE5 inhibitors with greater potency and selectivity than sildenafil
include vardenafil (Levitra, Nuviva) and tadalafil (Cialis).
3-Intracorporeal injection of vasodilators (e.g., papaverine, phentolamine) or
implantation of prosthetic devices are also used to treat erectile dysfunction.
4-Apomorphine hydrochloride (Uprima) increases sexual interest and erectile
function by increasing dopamine availability in the brain. It is dissolved
sublingually and its side effects include postural hypotension and syncope
(fainting).

PREMATURE EJACULATION:
Ejaculation with minimal sexual stimulation (before, upon, or shortly after
penetration) and before the person wishes it so that woman gains no pleasure. It is
common among young newly married men. It may improve with increasing
sexual experience.
Treatment includes:
-start technique (the woman interrupts foreplay whenever the
man feels highly aroused, in order to prolong the period of arousal before
reaching orgasm).
Flouxetine,
thioridazine) can be given few hours before sex.
VAGINISMUS:
An involuntary painful muscle spasm of the vaginal muscles (outer third) that
interferes with penile insertion. Thigh muscles may also contract. The condition
may be made worse by an inexperienced harsh partner. Some cases had past
history of sexual abuse. Anxious sensitive women are at higher risk. Both
situational and acquired dyspareunia may reflect a woman’s conscious or
unconscious motivation to avoid sex with a particular partner;
Complications include:
unconsummated marriage and divorce.
Treatment:
: exploration of the developmental and
interpersonal meanings of the need for the symptom.
Graded behavioral approach (woman is encouraged to gradually insert her
finger into vagina= pairing relaxation techniques with progressively larger
vaginal dilators) wait until anxiety disappears doing this repeatedly (with
increasingly larger probes) facilitates the process of muscle relaxation and
vaginal lubrication.
Paraphilias:
consisting of recurrent, intensely sexually arousing fantasies, sexual urges, or
sexual behaviors that involve either nonhuman objects, the suffering of the self or
partner, children, or non consenting persons.
ICD-10 Diagnostic Criteria for Disorders of Sexual Preference
G1. The individual experiences recurrent intense sexual urges and fantasies
involving unusual objects or activities.
G2. The individual either acts on the urges or is markedly distressed by them.
G3. The preference has been present for at least 6 months.
Fetishism
A. The general criteria for disorders of sexual preference must be met.
B. The fetish (some nonliving object) is the most important source of sexual
stimulation or is essential for satisfactory sexual response.
Fetishistic transvestism
A. The general criteria for disorders of sexual preference must be met.
B. The individual wears articles of clothing of the opposite sex in order to create
the appearance and feeling of being a member of the opposite sex.
C. The cross-dressing is closely associated with sexual arousal. Once orgasm
occurs and sexual arousal declines, there is a strong desire to remove the clothing.
Exhibitionism
A. The general criteria for disorders of sexual preference must be met.
B. There is either a recurrent or a persistent tendency to expose the genitalia to
unsuspecting strangers (usually of the opposite sex), which is almost invariably
associated with sexual arousal and masturbation.
C. There is no intention or invitation to have sexual intercourse with the
"witness(es)."
Voyeurism
A. The general criteria for disorders of sexual preference must be met.
B. There is either a recurrent or a persistent tendency to look at people engaging
in sexual or intimate behavior such as undressing, which is associated with sexual
excitement and masturbation.
C. There is no intention to reveal one's presence.
D. There is no intention of sexual involvement with the person(s) observed.
Pedophilia
A. The general criteria for disorders of sexual preference must be met.
B. There is a persistent or predominant preference for sexual activity with a
prepubescent child or children.
C. The individual is at least 16 years old and at least 5 years older than the child
or children in criterion B.
Sadomasochism
A. The general criteria for disorders of sexual preference must be met.
B. There is preference for sexual activity, as recipient (masochism) or provider
(sadism), or both, which involves at least one of the following:
(1) pain;
(2) humiliation;
(3) bondage.
C. The sadomasochistic activity is the most important source of stimulation or is
necessary for sexual gratification.
Multiple disorders of sexual preference
The likelihood of more than one abnormal sexual preference occurring in one
individual is greater than would be expected by chance. the different types of
preference and their relative importance to the individual, should be listed. The
most common combination is fetishism, transvestism, and sadomasochism.
Other disorders of sexual preference
A variety of other patterns of sexual preference and activity may occur, each
being relatively uncommon. These include such activities as making obscene
telephone calls to unknown persons (Scatologicia), rubbing up against people for
sexual stimulation in crowded public places (Frotteurism), sexual activity with
animals(zoophilia), use of strangulation or anoxia for intensifying sexual
excitement, and a preference for partners with some particular anatomical
abnormality such as an amputated limb.
Erotic practices are too diverse and many too rare or idiosyncratic to justify a
separate term for each. Swallowing urine, smearing feces, or piercing foreskin or
nipples may be part of the behavioral repertoire in sadomasochism. Masturbatory
rituals of various kinds are common, but the more extreme practices, such as the
insertion of objects into the rectum or penile urethra, or partial self-strangulation,
Practicing sex with cadaver (Necrophilia)
DSM-IV Diagnostic Criteria for Gender Identity Disorder
A. A strong and persistent cross-gender identification (not merely a desire for any
perceived cultural advantages of being the other sex).
In children, the disturbance is manifested by four (or more) of the following:
(1) repeatedly stated desire to be, or insistence that he or she is, the other sex
(2) in boys, preference for cross-dressing or simulating female attire; in girls,
insistence on wearing only stereotypical masculine clothing
(3) strong and persistent preferences for cross-sex roles in make-believe play or
persistent fantasies of being the other sex
(4) intense desire to participate in the stereotypical games and pastimes of the
other sex
(5) strong preference for playmates of the other sex.
In adolescents and adults, the disturbance is manifested by symptoms such as
a stated desire to be the other sex, frequent passing as the other sex, desire to live
or be treated as the other sex, or the conviction that he or she has the typical
feelings and reactions of the other sex.
B. Persistent discomfort with his or her sex or sense of inappropriateness in the
gender role of that sex.
In children, the disturbance is manifested by any of the following: in boys,
assertion that his penis or testes are disgusting or will disappear or assertion that
it would be better not to have a penis, or aversion toward rough-and-tumble play
and rejection of male stereotypical toys, games, and activities; in girls, rejection
of urinating in a sitting position, assertion that she has or will grow a penis, or
assertion that she does not want to grow breasts or menstruate, or marked
aversion toward normative feminine clothing. In adolescents and adults, the
disturbance is manifested by symptoms such as preoccupation with getting rid of
primary and secondary sex characteristics (e.g., request for hormones, surgery, or
other procedures to physically alter sexual characteristics to simulate the other
sex) or belief that he or she was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition.
D. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Gender Identity, Gender Role, and Sexual Orientation
Term
Gender
identity
Definition
Presumed
Etiology
Sense of self as Differential
being male or female exposure
prenatal
hormones
Comments
May or may not agree
to with physiological sex
sex or gender role (i.e.,
gender
identity
disorder)
Gender role Expression of one's
Societal pressure May or may not
gender identity in to conform to agree with gender
society
sexual norms
identity or
physiological sex
Sexual
orientation
Persistent and
unchanging
preference for
people of the same
sex (homosexual) or
the opposite sex
(heterosexual)
for love and sexual
expression
Differential
exposure to
prenatal sex
hormones
Genetic
influences
True bisexuality is
uncommon;
most
people have a sexual
preference
Homosexuality is
considered a normal
variant
of
sexual
expression
ILLNESS AND SEXUALITY
A. Heart disease and myocardial infarction (MI)
1-Men who have a history of MI often have erectile dysfunction. Both men and
women who have a history of MI may have decreased libido because of side
effects of cardiac medications and fear that sexual activity will cause another
heart attack.
2- Generally, if exercise that raises the heart rate to 110–130 bpm (e.g., exertion
equal to climbing two flights of stairs) can be tolerated without severe shortness
of breath or chest pain, sexual activity can be resumed after a heart attack.
3- Sexual positions that produce the least exertion in the patient (e.g., the
partner in the superior position) are the safest after MI.
B. Diabetes
1- One quarter to one half of diabetic men (more commonly older patients) have
erectile dysfunction. Orgasm and ejaculation are less likely to be affected.
2- The major causes of erectile dysfunction in men with diabetes are vascular
changes and diabetic neuropathy caused by damage to blood vessels and nerve
tissue in the penis as a result of hyperglycemia.
a- Erectile problems generally occur several years after diabetes is diagnosed
but may be the first symptom of the disease.
b- Poor metabolic control of diabetes is related to increased incidence of
sexual problems.
c- Sildenafil citrate and related agents often are effective in diabetes-related
erectile disorders.
d- Although physiologic causes are most important, psychological factors also
may influence erectile problems associated with diabetes.