9. Sexually Concerned Patient

Question 1

True or False

Sexuality in females typically decreases with age, while males’ sexuality tends to be unchanged throughout life.

Answer 1

True

Question 2

Describe: Sexual Dysfunction (2)

Answer 2

• Sexual dysfunction is some disturbance in sexual interest, arousal, or achieving orgasm.
• These are subdivided into male and female disorders:

Question 3

Name Sexual Dysfunctions (4)

Answer 3

• Male erectile disorder: difficulty in obtaining or maintaining an erection during sexual activity
• Female orgasmic disorder: infrequent or absence of an orgasm or a reduction in the intensity of an orgasmic sensation
• Female sexual interest/arousal disorder: absent or reduced interest in sexual activity, erotic thoughts, sexual excitement, and sexual arousal
• Male hypoactive sexual desire disorder: absent or reduced sexual or erotic thoughts and pleasure in sexual activity

Question 4

Describe: Sexual Paraphilia (4)

Answer 4

• Sexual arousal, fantasies, sexual urges or behavior involving nonhuman objects, suffering or humiliation of oneself or one’s partner, children, or others
• Rarely self-referred, and often come to medical attention through interpersonal or legal conflict
• Person usually has more than one paraphilia, with only 5% of paraphilia diagnoses attributed to women
• Typical presentation begins in childhood or early adolescent, increasing in complexity and stability with age but decreasing with advancing age although with chronic presentation, and may increase with psychosocial stressors

Question 5

Describe: Gender Dysphoria (5)

Answer 5

• Strong and persistent cross-gender identification with repeated stated desire or insistence that one is of the opposite sex. Often have an intense desire to participate in the stereotypical games and pastimes of the opposite sex and significant distress or impairment in functioning with his or her sex or gender role.
• Further subdivided into gender dysphoria in children and gender dysphoria in adolescents and adults, which have unique criteria in DSM-5 catered to differences in behaviors seen in children and adults/adolescents.
• Gender identity is set in most people by age 2 or 3 yr.
• Behavioral interventions should be considered first line for management of problem.
• Boys develop the disorder before age 4 yr, while girls mostly give up masculine behavior by adolescence.

Question 6

Define: Exhibitionism

Answer 6

Recurrent urge of behavior to expose one’s genitals to an unsuspecting person

Question 7

Define: Fetishism

Answer 7

Use of nonsexual or nonliving objects or part of a person’s body to gain sexual excitement

Question 8

Define: Frotteurism

Answer 8

Recurrent urge or behavior of touching or rubbing against a nonconsenting person

Question 9

Define: Voyeurism

Answer 9

Recurrent urge or behavior to observe an unsuspecting person who is naked, disrobing, or engaging in sexual activities, or may not be sexual in nature at all

Question 10

Define: Pedophilia

Answer 10

Sexual attraction to prepubescent or peripubescent children

Question 11

Define: Sexual masochism

Answer 11

Recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer for sexual pleasure

Question 12

Define: Sexual sadism

Answer 12

Recurrent urge or behavior involving acts in which the pain or humiliation of the victim is sexually exciting

Question 13

Define: Transvestite fetishism

Answer 13

Sexual attraction toward the clothing of the opposite gender

Question 14

Define: Necrophilia

Answer 14

sexual attraction to corpses

Question 15

Define: Zoophilia

Answer 15

sexual attraction to animals

Question 16

Define: Coprophilia

Answer 16

sexual pleasure from feces

Question 17

Define: Urophilia

Answer 17

sexual pleasure from urine and urination

Question 18

Describe general observations and physical exam: Paraphilia (2)

Answer 18

• Observe for general appearance, appropriateness of behavior, body language, distress, agitation, masculine/feminine features
• Examine vital signs, puberty staging, thyroid gland, weight changes, drug and/or alcohol use (needle injection, alcohol breath), concentrate on neurologic exams (especially peripheral neuropathy), and genital exams

Question 19

Describe investigations: Paraphilia (2)

Answer 19

• Blood work = CBC, electrolytes, BUN, creatinine, fasting blood glucose, liver profiles, thyroid profiles (TSH), toxicology/drug screen (alcohol, opioid, amphet- amine/stimulant or cocaine withdrawal or intoxication), FSH/LH, GH
• Additional screening: neurologic/endocrinology/gynecology/urology consultations, CXR, ECG, CT scan as indicated

Question 20

Describe management: Paraphilia (10)

Answer 20

• A full assessment including family evaluation to identify emotional, behavioral, and separation problems is essential, and unresolved issues in the child’s environ- ment are often present such as loss.
• Direct assessment and treatment of other underlying disorders including GMCs and psychiatric disorders should be promptly initiated.
• Testosterone = control of sexuality, fantasies, and behavior; also increases the frequency, duration, and magnitude of spontaneous and nocturnal erections
• Antiandrogenic drugs such as medroxyprogesterone (long-acting contraceptive Depo-Provera) have been used to reduce sex drive in men, but they have many unpleasant side effects, including breast growth, headaches, weight gain, and re- duction in bone density.
• SSRIs and lithium have been used to reduce impulse control problems and/or sexual obsessions, and psychostimulants have been used to augment the effects of SSRIs in individuals with a paraphilic disorder.
• Psychotherapy including individual or group therapy and behavioral modification should aim to assist development, particularly that of gender identity, by exploring the nature and characteristics of the atypical organization of the child’s or adolescent’s gender identity, and focusing on ameliorating the comorbid problems and difficulties in the child’s life while reducing the distress being experienced by the child.
• Recognition of the person’s inability to control the compulsion, acceptance of the disease and its consequences, and willingness to learn from others in recovery with commitment to change should be discussed.
• Therapist should also provide recognition and acceptance of the gender identity problem and remove its secrecy, while providing guidance for the child’s sense of gender identity and support for the family in tolerating uncertainty and anxiety in relation to the gender identity development and how best to manage it.
• Referral for assessment and/or treatment in a multidisciplinary gender iden- tity specialist service should be made if the criteria of gender identity disorder are met.
• Referral to a pediatric endocrinologist for the purpose of physical assessment, education about growth and endocrinology problems, and involvement in any decision about physical interventions should be considered.