Chapter 17: Sexual Dysfunctions Cindy M. Meston Carey S. Pulverman

Sexual Dysfunction Defined The inability to participate in a sexual relationship as one wishes Sexual problems that are personally distressing, persistent, and recurrent Four main categories of disorders: Sexual desire Sexual arousal Orgasm Sexual pain Subtypes: Lifelong vs. acquired, generalized vs. specific

DSM-5 Revisions: An Overview Addition of severity and duration (6 months) criteria for all sexual disorders Eliminated Sexual Aversion disorder Newly combined disorders: Hyposexual sexual desire disorder in women and female sexual arousal disorder  female sexual interest/arousal disorder Dyspareunia and vaginismus  genito-pelvic pain/penetration disorder Name changes for: Male orgasmic disorder (now delayed ejaculation) Premature ejaculation (now early ejaculation)

Sexual Desire Disorders Hypoactive Sexual Desire Disorder Deficiency in, or absence of, sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty * For females is now combined with female sexual interest/arousal disorder. For males, retained as HSDD. Hypersexual Disorder Incessant sexual desire, fantasy, or thoughts that may lead to excessive or dangerous sexual activity. Was considered but not added to DSM-5.

Hypoactive Sexual Desire Based on theories of Masters and Johnson (1966) and Kaplan (1979), in which desire precedes arousal and orgasm in a linear, sequential fashion but since the order is not as clear for women, this has now been combined 32% of young adult U.S. women and 14% of young adult men report lack of sexual interest Sexual desire problems are the most common type of sexual complaints reported by women

Problems with Hypoactive Sexual Desire Biological and Psychological Etiological Factors Hormone levels: Androgens and estrogens Psychotherapeutic drugs and conditions Daily hassles and relationship stress/satisfaction Negative perceptions of sexuality, history of sexual abuse Assessment and Treatment A complete sexual, medical, and psychosocial history Blood serum tests to evaluate hormone levels Testosterone replacement therapy Pharmacological treatments (e.g., buproprion, apromorphine) Sensate focus therapy Identifying distracting thoughts, sexual preferences

Sexual Arousal Disorders Erectile Dysfunction (ED) The inability to reach or maintain adequate erection of the penis to engage in intercourse. This includes a decrease in erectile rigidity Female Sexual Arousal Disorder (now combined with female sexual interest difficulty) Persistent or recurrent inability to attain (or maintain until completion of sexual activity) an adequate genital lubrication-swelling response of sexual excitement that causes marked distress or interpersonal difficulties

Erectile Dysfunction DSM Diagnostic Criteria Inability to reach/maintain erection or erectile rigidity occurs all or almost all of the time for at least 6 months Biological Etiological Factors 60%-80% of ED cases are organic in nature. Surgery, chronic illnesses and vascular disorders can all interfere with the normal blood inflow to the corpora cavernos Drugs that reduce testosterone, increase dopamine, or interfere with the increase in parasympathetic activity that facilitates penile smooth muscle relaxation required for erection

Erectile Dysfunction (cont.) Psychological Etiological Factors Anxiety Negative Expectations Spectatoring: Focus on performance instead of pleasure Assessment Identifying situations and beliefs surrounding ED onset Measurements of genital blood inflow and outflow, nocturnal erections, free and bioavailable serum testosterone Treatment Vacuum and constriction devices, penile implants Pharmacotherapy (e.g., injections, creams, Viagra, and other phosphodiesterase type 5 - PDE5 inhibitors)

Female Sexual Arousal Difficulties DSM Diagnostic Criteria and Prevalence Persistent, recurrent inability to attain or maintain genital response to sexual excitement, which causes marked distress or interpersonal difficulty and lasts for at least 6 months Some issues with a sole focus on genital response in criteria 20% estimated lifetime prevalence of related problems Biological and Psychological Etiological Factors Estrogen and androgen levels Sympathetic and parasympathetic nervous system integrity General mood and feelings about one’s body Feeling desired by a partner Worry about the consequences of sexual behavior

Female Sexual Arousal (cont.) Assessment and Treatment A comprehensive review of an individual’s sexual, medical and psychosocial history, as is done for HSDD in women Vaginal photoplethysmograph assessment, fMRI Topical lubricants PDE5 inhibitors? Vasodilator drugs EROS clitoral therapy device

Orgasm Disorders Delayed Ejaculation Early Ejaculation Delayed or inhibited ejaculation following normal sexual arousal and adequate sexual stimulation. Early Ejaculation Ejaculation that occurs with limited stimulation before, or shortly after, penetration and sooner than the man desires Female Orgasm Disorder (FOD) The persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase

Ejaculation Disorders DSM Diagnostic Criteria and Prevalence Delayed: Delayed or inhibited ejaculation must occur all the time or most of the time for at least 6 months Affects only 3% of the population, often only affects men during intercourse Early: Ejaculation occurs with little stimulation and ejaculation latency is lower than the man desires Typically men ejaculate within the first minute of intercourse. Most commonly reported male sexual disorder: 30% of U.S. men

Ejaculation Disorders (cont.) Biological and Psychological Etiological Factors Deficiency in the afferent or efferent sympathetic nervous circuits involved in the ejaculatory process Arousability/response to visual stimuli Anxiety? Perceived control over ejaculation Assessment and Treatment Assessment of ejaculation latency, feelings of control over ejaculation, distress caused by problems “Squeeze” and “pause” techniques Couple’s foreplay Use of PDE5 inhibitor, topical anesthetics

Female Orgasmic Disorder DSM Diagnostic Criteria and Prevalence Delay, absence of orgasm during a sexual encounter must be persistent and recurrent (for ≥ 6 months), and cause marked distress or interpersonal difficulty A woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives The second most frequently reported type of sexual problem for U.S. women, affecting between 22% and 28% of adult women

Female Orgasmic Disorder (cont.) Biological and Psychological Etiological Factors Impairments in endocrine, nervous system, brain function Medical conditions Psychotherapeutic drug use Sexual guilt, religiosity, sexual inexperience Mainly thought to be related to psychological factors Assessment and Treatment Comprehensive sexual, medical, and psychosocial history Sensate focus, systematic desensitization, sexual education Directed masturbation

DSM-5 Genito-pelvic pain/penetration Disorder: combined dyspareunia and vaginismus Persistent and recurrent genital pain during intercourse, or in situations other than sexual encounters (e.g., gynecological examinations) Vaginismus Repeated and persistent involuntary spasm of the outer third of the vaginal muscles that interferes with penetrative intercourse

Dyspareunia Characteristics and Prevalence Ongoing (≥ 6 months) experiences of sharp, dull, burning or shooting pain in the vaginal area or other areas of the pelvis Shares many characteristics with pain disorder Affects up to 16% of U.S. women Biological Etiological Factors Medical conditions (e.g., injury, urinary tract or yeast infections, endometriosis, uterine fibroids) Provoked Vestibulodynia (PVD): Pain resulting from sensitivity to touch or pressure of the vulvar vestibule Vulvovaginal Atrophy: Deterioration and reduction of lubrication of postmenopausal vaginal tissue

Dyspareunia (cont.) Psychological Etiological Factors Assessment Fear of pain, anxiety associated with sexual activity Negative attitudes, depression Assessment Description of the location, intensity, quality, duration and time course of pain, as well as its interference with sexual activity. Gynecological, physical therapy exams. Treatment Cognitive behavioral therapy (CBT) Electromyographic feedback Vestibulectomy and pelvic floor training Postmenopausal estrogen administration

Vaginismus Characteristics and Prevalence Repeated vaginal spasms that prevent intercourse that persist for at least 6 months Highly comorbid with FSAD. Affects between 1% to 6% of female adults Biological and Psychological Etiological Factors Provoked PVD: Response to anticipated sexual pain Anxiety and negative beliefs about sexuality History of sexual abuse Assessment and Treatment Systematic desensitization