1. Sexual disorders and Gender Identity disorders

2. Objectives Describe the common sexual dysfunctions which present to primary care physicians Describe the the treatments for the common sexual dysfunctions Describe the effect of common medical illnesses and medications on sexual functioning Describe the gender identity disorders Describe the disorders of ambiguous genitalia

3. Review of the Human sexual response cycle Desire Excitment (vasomotor) Orgasm Resolution

4. Sexual dysfunctions May be lifelong or acquired May be situational or generalized In primary care the contribution of medication and medical illness is very high

5. Disorders of Sexual desire Classically divided into two groups Hypoactive Sexual desire disorder Deficiency of fantasies and desire for sex females > males est. 20% of the population Sexual aversion disorder Self explanatory

6. Disorders of desire May be related to psychologic distress Often associated with hostility or dysfunction in the couple May be secondary to medical illness or medication Vagina dentata- male unconscious fantasy that the vagina has teeth. Another contribution by Freud

7. drugs which enhance libido Levodopa/carbidopa fenfluramine fluvoxamine trazadone testosterone ethosuximide

8. Disorders of excitement Female sexual arousal disorder inability to attain the lubrication-swelling response for the duration of the sexual act as many as 33% of married couples may develop as a consequence to dyspareunia medications such as anticholinergic and antihistaminic drugs may contribute

9. Disorders of excitement Male erectile disorder(impotency) recurrent or persistent difficulty in attaining or maintaining an erection until the completion of the sexual act may be total or partial may be situational or generalized 10-20% of men most are psychological history is the most useful evaluation tool consider medications, erectile patterns with sleep, etc.

10. Disorders of orgasm Male orgasmic disorder inhibited ejaculation with coitus few complaints compared to premature ejaculation Premature ejaculation again it’s clinical judgement more common in college educated men effect of conditioning treat with the squeeze technique

11. Disorders of orgasm Female orgasmic disorder (anorgasmia) Clinician judgement as to what constitutes a period of adequate stimulation inhibited orgasm with both masturbation and coitus lifelong anorgasmia-5% of women episodic or acquired anorgasmia- as much as 46% best estimate of total anorgasmia is about 30%

12. Sexual pain disorders and other sexual dysfunctions Dyspareunia- pelvic pathology is not uncommon-infections of bartholin’s glands, vaginitis, cervicitis, endometriosis, myomata Vaginismus Post coital headache, post coital dysphoria, orgasmic anhedonia (think SC pathology)

13. treatments Sensate focus- for inhibited desire, excitement phase disorders Squeeze technique and the stop start technique - for premature ejaculation dual sex therapy homework and “spectatoring “ medications- generally disappointing unless there is another psychopathology present. Surgical-realistic expectations Other rx-vacuum pumps, injections

14. Medications and sexual fucntioning Medications can affect Libido erectile function orgasmic ability ejaculation

15. Summary of med effects

16. Sex and the Heart Patient Frequently unspoken concerns frequent reduced activity and increased perception of dysfunction Resuming sex with usual partner in usual setting does not increase morbidity Most impediments are psychological Full return in 2-3 months

17. Sex and the Heart Patient medication effects May need to change practices Prohpylactic nitroglycerin may be needed Harlot’s Heart attack

18. Sex and the cancer patient consequences of pelvic radiation may not appear for months In men cancer of the prostate may impair erectile functioning Effects on body image and self esteem may inhibit sexual expression

19. Sex and the renal patient Renal failure is accompanied by alterations in endocrine and metabolic functions reduced libido and impotence is common Anemia reduces energy Medications affect sexual functioning Transplantation usually results in improved functioning

20. Sex and diabetes mellitus Neuropathic, hormonal, and vascular changes reduce sexual functioning psychosocial factors are important contributors and must be addressed for successful outcome

21. Sex and HIV/AIDS hypoactive sexual desire disorder common post notification of disease status sexual education is necessary absolutism is a dangerous attitude Attention to major depression and anxiety disorders may help

22. Paraphilias and Gender disorders Paraphilias can also be conceptualized as disorders of arousal and desire Pathologic fantasy May involve disorder of object choice or in sexual practices (ex:sadism) Beyond simple experimentation (must impair functioning) Gender identity disorders - The belief that you are psychologically the opposite sex from your genital/biological sex

23. Paraphilias Characterized by specialized sexual fantasies and intense sexual urges and practices that are repetitive and disteressing to the person may be harmful to another may disrupt the capacity for bonding may be transient Usually more than one is present

24. Paraphilia Some biologic findings evidence of abnormal hormones74% evidence of hard and soft neurologic signs 27% chromosomal abnormalities in 24% seizures in 9% MR-4% other major psychiatric illness-4%

25. Paraphilia types Exhibitionism frotteurism sexual sadism Voyeurism Zoophilia coprophilia and klismaphilia urophilia Fetishism pedophilia sexual masochism Transvestic fetishism Necrophilia telephone scatologia hypoxyphilia partilaism

26. Pedophilia Legal dimensions at least 16 y/r victim at least 5yrs younger (prepubescent) majority involve fondling and oral sex penetration is infrequent except in incest Offenders report 60% of victims are boys but victim reports are most often girls 50% are associated with excess alcohol at the time

27. Gender identity disorders Gender identity is the sense of ones sexual identity Gender role is the external behavior relfecting the gender identity Sexual orientation is related to object choice Gender identity disorder criteria are in the book

28. More related terms Transsexual-person with desire to change sexual assignment Transvestite- person with a sexual fetish to cross dress (if only during stress the dx is cross- dressing) Person is not interested in sexual reassignment Homosexual- person with an sexual object choice of the same sex. Transsexual may have same or opposite object choice.

29. Transsexualism Gender identity disorder of childhood is a suspect diagnosis In prospective studies few actually meet criteria of transsexualism in adulthood there is an increase in homosexual orientation in this group on followup the person undergoes a period of transition 3-12 months where they live as the target sex. some stop after recieving hormonal therapy only Adjustment is variable and outcome studies are limited.

30. Intersex conditions Turner’s syndrome- XO Primary amenorrhea, and infertility Klinefelter’s- XXY somewhat effeminate aith small genitalia, usually reduced sexual desire, gender identity disorders are common

31. Intersex conditions Adrenogenital syndrome- excess virilizing adrenal hormones masculinized behavior Pseudohermaphroditism - considered an obstectrical emergency? use of chromosomes to intially assign sex (for parents) Surgery at a later date (before 3y/r Androgen insensitivity syndrome Lack androgen receptors

32. Intersexual disorders Occur when there is a conflict in chromosomal and phenotypic sexual identity Turner’s-XO- lack of Y chromosome and therefore a lack of SRY Phenotypic female Androgen insensitivity syndrome (T-fem) XY but lacks androgen receptors have undescended testes-with MIS(no female genital tract phenotypic female/chromosomal male