Behavioural Disorders

Question 1

Sexual Dysfunction

Answer 1

Common presentations include Sexual Dysfunction, Abnormalities of Sexual Preference,
Disorders of Gender Identity and Psychological Problems faced by Homosexual peoples

Question 2

Sexual Dysfunction Epidemiology

Answer 2

Earlier sexual maturity, relaxation of social
attitudes; More than 80% by 20yrs in males and females
o Earlier age associated with lower SES, education and lack of religious affiliation
o 96% of men, 97% of women report mostly/exclusively heterosexual experience and
attraction; 1% of men and 0.25% of women mostly/exclusively homosexual

Question 3

Normal Sexual Response: Male

Answer 3

Erection, Scrotal skin thickens, and Testes are raised; HR/BP increases; At orgasm, the
Urethra contracts repeatedly, RR/HR/BP increases further; Resolution with physiological
markers returning to normal and gradual detumescence of the Penis

Question 4

Normal Sexual Response: Female

Answer 4

Nipple Erection, Clitoral Swelling, Vaginal Lubrication, Expansion and Distention of
inner two-thirds, Uterine Body and Cervix raised with raised physiological markers; At orgasm,
the outer third of the vagina swells and contracts, Uterus contracts and physiological markers
peak; Resolution with physiological markers returning to normal, Cervical os gapes open

Question 5

Considerations for Sexual Dysfunction

Answer 5

Patients might not be comfortable discussing
sexual problems initially; Might ask for help
regarding anxiety, depression, poor sleep or
gynaecological problems
o Important to routinely ask questions
about sexual functioning when assessing
patients with non-specific psychological
or physical symptoms

Question 6

Assessing Sexual Dysfunction

Answer 6

Define the problem (Nature, Duration, whether it
is this partner only), Sexual Drive (Arousal, Intercourse and Masturbation)
o Martial/Social Relationships, Sexual Development (including Traumatic Experiences)
o O&G and Past Psychiatric History, Mental State (Especially for Depressive Disorder),
o Assess Motivation for treatment and Examination/Investigation for Organic causes
o Examine for PVD, Adrenal Disorders, Diabetes Mellitus and Neuropathy,
Abnormalities of the Genitalia

Question 7

Low Sexual Desire

Answer 7

More common in women; If has always been low =Primary Low Sexual Desire; May extreme
range of biological variation, or adverse experiences in childhood (e.g. Sexual Abuse)

Question 8

Low Sexual Desire: Secondary Causes

Answer 8

General problems in the relationship, Physical Disorders (Hypogonadism,
Heart Disease, Epilepsy, Renal Disease, Hypothyroidism, Gynaecological Surgery, GI surgery),
Medications (Hypnotics, Anxiolytics, Antipsychotics), or Depressive Disorder

Question 9

Low Sexual Desire: Treatment

Answer 9

Treatment of underlying causes, Couples therapy; Fear and Guilt caused by adverse experiences in early life may respond to psychotherapy

Question 10

Male Erectile Dysfunction

Answer 10

Instability to achieve
erection, or sustain it long enough for satisfactory
coitus; Primary ED might be Neurological Damage
or Vascular Issues

Question 11

Secondary ED

Answer 11

Anxiety, ETOH, Drugs,
Diabetes, Arteriosclerosis or Age-related
o Ask about Erections waking from sleep,
and during masturbation; If present
physical causes are unlikely

Question 12

Male Erectile Dysfunction Treatment

Answer 12

Treatment should include sexual therapy techniques and anxiety management;
Physical treatments include Sildenafil (PDE V Inhibitor, increasing NANC conduction),
Intracaverosal Smooth Muscle Relaxants (Papaverine, Prost E2), Vacuum devices,
Surgical management

Question 13

Premature Ejaculation

Answer 13

Common among young men during first sexual encounters and improves with experience; Can assist by interrupting foreplay when man feels himself being
highly aroused (stop-start)

Question 14

Retarded Ejaculation

Answer 14

Might be part of general psychological inhibition about relations with
women; Can also be due to drugs (E.g. Antipsychotics, SSRIs, MAOI); Psychotherapy may help

Question 15

Vaginismus

Answer 15

Painful spasm of Vaginal Muscles during intercourse; Might be due to aversion,
or painful scarring following procedures (e.g. Episiotomy)
o Made worse by inexperienced, or inconsiderate partners; Generally, begins when
man attempts penetration, but if severe might occur with finger
o Psychoeducation, Graduated Behavioural Approach, Graduated Dilators
o Distinct from lack of Vaginal Lubrication – Usually due to lack of sexual arousal; Also,
drug side effects and physical disorders (E.g. Diabetes); More common Post- menopausal; Treatment of underlying disorders, use of Personal Lubricants

Question 16

Dyspareunia

Answer 16

Painful on Intercourse; Might be due to impaired lubrication (Aversion,
Inadequate Foreplay), or painful scarring
o If Deep Dyspareunia – Might be due to Pelvic Pathology E.g. Endometriosis, PID,
Ovarian Cysts, Tumours
o Sexual Therapy techniques if impaired sexual arousal
o Referral to Gynaecologist appropriate for Organic disorders

Question 17

Inhibited Female Orgasm

Answer 17

Frequent, although most women can achieve through clitoral stimulation; Causes include Partner factors, Tiredness, Depressive Disorder, Physical Illness of
Medication side effects; Sexual Therapy or Martial Therapy where appropriate

Question 18

Psychological Therapies for Sexual Dysfunction

Answer 18

• Communication – Help couple talk freely, and understand wishes and feelings of the other;
Improve relationship affection and satisfaction
• Education – Regarding sexual responses, Self-Help and resources
• Graded Activities/Sensate Focus – Mutually agreed ban on full sexual intercourse; Focus onto
physical contact (initially not genitalia); Then genital foreplay; Graded insertion/movement
• Partner with greater problems sets the pace; Avoid checking own state of sexual arousal
• 1/3 successful, 1/3 worthwhile improvement; Low sex drive generally poorer outcome

Question 19

Disorders of Sexual Preference

Answer 19

• Abnormal if most people in a society regard it as abnormal; If it can be harmful to other
people, and the person with the preference suffers from its consequences
• Might be associated with other disorders including Depression, ETOH and Dementia

Question 20

Fetishism

Answer 20

Inanimate object is preferred or only means to achieving sexual excitement;
Almost all are male, most are heterosexual; Commonly Rubber Garments, Women’s
Underclothes, High Heeled shoes; Smell, Texture and Appearance

Question 21

Fetishistic Transvestitism

Answer 21

Repeatedly wears clothes of opposite sex as preferred, or only
means of sexual arousal; Nearly all male
o Crossdressing nearly always begins after puberty; Initially privately, some might wear
in public with or without precautions against discovery
o Sexually aroused by wearing the clothing, C/f Trans-sexual

Question 22

Exhibitionists

Answer 22

Exposure of genitalia to unprepared stranger; Usually preceded by period of
mounting tension released by the act
o Some are males with inhibited temperament, who generally exposure flaccid penis
and feel much guilt after the act
o Some are males with aggressive personality traits who exposure erect penis while
masturbating, while feeling little guilt after

Question 23

Voyeurism

Answer 23

Observing others; Most are inhibited heterosexual men; Some spy on couples
having intercourse, others on women undressing/naked

Question 24

Sadomasochism

Answer 24

Bondage, Inflicting pain; Beating, Whipping and Tying; Sometimes symbolic
and cause little actual damage
o Mild Sadomasochism is common and considered to be part of normal range

Question 25

Management of Disorders of Sexual Preference: Assessment

Answer 25

Problem and course; Exclude Mental Disorder
o Assess Normal Sexual Functioning and Role of the Abnormal Behaviour – Might be as
coping with Isolation, Depression, Anxiety
o Assess Motivation for Treatment

Question 26

Management of Disorders of Sexual Preference: Techniques

Answer 26

• Sexual Counselling, Management of Sexual Dysfunction
• Distraction – Control of fantasies as they might reinforce and maintain; Stop using
pornographic materials to simulate fantasies
o New interests to occupy time previously spent on seeing out stimuli
• Anti-Androgens and Oestrogen are used to reduce sexual drive, especially if danger to others;
Benefits of such treatment not clearly established

Question 27

Transsexualisms

Answer 27

• Person has conviction of being opposite sex to that indicated by external genitalia; Wishes to
alter to resemble, and to live as member of opposite sex
o Typically, conviction begins before puberty but medical help not requested until early
adult life, by then most would have cross-dressed
o C/f Transvestites – Do not derive sexual arousal from crossdressing
• Most are males; C/f Most females who cross-dress and imitate men are homosexual

Question 28

Transsexualisms: Treatment

Answer 28

Female speech, Removal of Body Hair, Increase Breast Tissue (Oestrogen, Surgery); Might seek Sex Reassignment Surgery