Sexual disorders and Gender Identity disorders

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