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The three categories of sexual disorders
1. Sexual dysfunction - most common

2. Paraphilias - most irritating to others and society

3. Gender Identity Disorders - rare but may be very troubling for individuals.
The four categories of sexual dysfunction
1. Sexual Desire Disorders: hypoactive sexual desire disorder, sexual aversion disorder.

2. Sexual Arousal Disorders: Female sexual arousal disorder, male erectile diorder.

3. Orgasmic Disorders: Female orgasmic disorder, Male orgasmic disorder, Premature ejaculation

4. Sexual Pain Disorders: Dyspareunia, Vaginismus
The definition and diagnostic feature of: Hypoactive sexual desire disorder
- Persistent or recurrent deficiency in or absence of sexual fantasies and desire for sexual activity

- Over 1/3 of women have temporarily met criteria

- 5% of men have met criteria

- Stressors: overwork, lack of privacy, little opportunity for sexual contact

- Treatment: dual sex therapy
The definition and diagnostic feature of: Sexual aversion disorder
- Persistent avoidance of genital contact
- May experience extreme fear, panic, and digust at sexual contact
- May be component of OCD or depression, must rule out before diagnosis
- High prevalence of sexual abuse/victimization
- Treatment: dual sex therapy
The definition and diagnostic feature of: Primary and secondary impotence
- Priamary impotence: when a man has never able to achieve erection sufficient for intercourse - rare

- Secondary impotence: when a man has been able to achieve an erection for intercourse sometime in the past but develops difficult getting or maintaining an erection

- Affect 1/4 of all men and 50% seek treatment, 2 fold increase with each decade

- Most common cause is atherosclerosis - 40%

- 18% had undiagnosed hypertension, 16% had diabetes and 5% had ischemic heart disease - important to screen for these disease in every men

- Psychosocial factors may play a role: erections occur upon awakening, with masturbation or periodically throughout the day

- Treatment:
a) medication: Sildenafil (Viagra), vardenafil, or tadalafil --> increase NO

b) Vacuum pump devices increase blood flow to penis causing erection

c) Penile prosthesis
The definition and diagnostic feature of: Female sexual arousal disorder
- Failure to attain or maintain lubrication-swelling response or complete lack of excitement and pleasure
- May retain desire but have difficulty with arousal --> develop anxiety with any sexual encounter
- Hormone problem must be rule out
- Usually associate with anorgasmia
- Affect 1/3 of all married women
- Treatment:
a) medication: Hormone replacement/supplementation improve vagina dryness
b) Natural estrogens may be effective
The definition and diagnostic feature of: Female and male orgasmic disorders
- Delay in or absence of orgasm following a normal excitement stage
- Patients have adequate desire and arousal stage
- 25% women report difficult achieving orgasm
- Dual sex therapy usually employed and encourage masturbation
The definition and diagnostic feature of: Premature ejaculation
- Persistent or recurrent ejaculation with minimal stimulation before the man wants to ejaculate
- Common disorder by about 21% of married men
- Problem decline with age
- Technique for treatment:
a) Squeeze method
b) SSRI - delay ejaculation
c) Topical anesthetic creams
d) Condoms
The definition and diagnostic feature of: Dyspareunia
- Painful intercourse in males or females

a) Must not be solely due to lack of lubrication or vaginismus

- Treatment: dual sex therapy, psychotherapy, hegar dilators

b) Common among women who have had pelvic surgery
The definition and diagnostic feature of: Vaginismus
- Involuntary muscle contractions making penile insertion painful

Treatment: Dual sex therapy, Psychotherapy, Hegar dilator- enlarge vaginal opening
Rate of physical causes of impotence
- Atherosclerosis - 40%
- Undiagnosed hypertension - 18%
- Diabetes - 16%
- Ischemic Heart Disease - 5%
How to distinguish between impotence secondary to physical vs. psychological factors
- It is is important to note if erections occur upon awakening, with masturbation or periodically throughout the day - presence of any above would indicate psychosocial factors involve
Understand the basics of Masters and Johnson's dual sex therapy, including the purpose of prescribing sensate focus treatment
- Involve both partners
- Address psychological and physiological aspects of sexual functioning
- Sensate focus - excerise that encourage sensory awareness of erogenous zones.  Involve nonsexual, nondemanding touching/massage, etc.  Sexual intercourse prohibited during this stage - couples are encourage to get sexual pleasure from sensate focus activities
- Goal is to get pressure off intercourse and decrease anxiety about sex
What must be present to characterize a sexual activity as paraphilic
- Disturbance in the object or expression of sexual satisfication

i. Preference for non-human objects

or

ii. Imposing humilitation or suffering

or

iii. Involvement of nonconsenting partners
Exhibitionism
Exposure of genitals to unsuspecting strangers
Fetishism
Sexual attraction to nonliving objects - inanimate objects are the PREFERRED or ONLY means of sexual gratification

Related to partialism - sexual gratification linked to one particular body part
Frotteurism
Rubbing one's genitals against nonconsenting persons
Pedophilia
Repeated sexual activity with prepubertal children

- Most are male
- Most common paraphilia
- Uncomfortable with adult interaction
- Engage in morally compensatory behavior
- Not all child molesters are pedophiles
- True pedophiles require pharmcologic interventions to decrease sex drive in order to reduce risk to others and strenthening of adult social skills
Sexual masochism
Suffering pain or humiliation to attain sexual gratification
Sexual sadism
Inflicting pain or humiliation to attain sexual gratification
Transverstic fetishism
Arousal with the act of dressing in clothing of the opposite sex
Voyeurism
- Observing an unsuspecting individual undressing or naked
- the risk of being caught is neccessary for arousal
The role of masturbation/orgasm in reinforcing the development of paraphilic patterns of behavior
Inappropriate sexual fantasies repeately associated with masturbatory activities ==> Strong reinforcement ==> repeated attempts to inhibit undesired arousal and behavior resulting in increase in paraphilic thoughts, fantasies and behavior ==> paraphilia
The gender and sexual orientation of most persons with paraphilias
Common comorbid psychiatric conditions in persons with paraphilias
Anxiety, mood disorders, and substance abuse
How behavioral principles are applied to treatment of paraphilias
- Convert sensitization - replace fantasies with unpleasant images
- Orgasmic reconditioning - encourage appropriate fantasy through repeated masturbation
- Family/marital therapy
- Coping and relapse prevention
Mechanisms of action of medications used for paraphilias
1. Testosterone-lowering medications (Depo-Provera or medroxyprogesterone): work centrally to decrease sexual drive by decreasing level of LH and FSH

2. SSRI's - decrease sexual fantasies and urges due to side effect of lowered libido.  SSRI's are also useful in reducing the compulsive tendencies in those with paraphilias
Definition and characteristics of gender identity disorder
A condition in which a person has been assigned one gender but identifies as belong to another gender

- A key feature is gender dysphoria: discomfort iwth one's assiged gender

Differential diagnosis:

- Schizophrenia
- Transvestic fetishism
Age at which gender identity disorder develops
- About age 2 or 3
- In boys, overidentification with mother, interest in traditional female play
- In girls, often tomboyishness is an early feature
- High correlation between Gender identity disorder in childhood and homosexuality
Common comorbid psychiatric conditions with gender identity disorder
- Depression : 35%
- Substance abuse : 12%
- Absentee fathering: 46%
- Suicide rate : 20%
- High rate of personality disorder, self mutilation, separation anxiety
Understand basics of management of gender identity disorder, including criteria for sex reassigment surgery
- Early intervention : focus on self-esteem and becoming a happier child
- Acceptance of oneself not as male or female but rather as a person with a unique, transgender identity
- Gender reassignment consists of 3 stages

a) Real life experience:
b) Hormonal therapy:
- must be 18 yrs old,
- must demonstate knowledge of health risks associated with hormone treatment,
- generally a minimum of 3 months of real-life experience is require,
- psychiatric disorder must be stable
c) Surgical intervention:
- 12 months of real life experience
- 12 months of hormonal therapy
- Following gender reassignment, the majority of patients improve
  • 87% of satification of male to female transexual and 97% of satification for F to M transexual
  • Suicide rate after surgery drops to 0.5%
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