Lecture 23 Sexual Dysfunctions Flashcards
define sexual health
a state of physical, emotional, mental and social well-being relating to sexuality.
not merely the absence of disease, dysfunction or infirmity.
define sexual dysfunction
‘the various ways in which an individual is unable to participate in a sexual relationship… he/she would wish’.
prevalence of sexual problems
at least one sexual dysfunction:
40-45% women
20-30% men
aus women in hetero relationship:
at least 1 sexual difficulties: 66%
at least one new sexual difficulty during previous 12 months: 36%
limitations of measuring sexual dysfunction prevalence rates
different samples:
- age group 18+,40+, 70+
- clinical vs non-clinical
different measurements: -self-report vs clinical interview -asking the right question eg. sex != coital intercourse sexual satisfaction != preserved/restored functionality
Kaplan’s triphasic models of sexual response
desire
excitement
orgasm
Basson’s non-linear model of female sexual response
re-conceptualisation of female sexual dysfunction
-circular rather than linear
acknowledges how emotional intimacy, sexual stimuli and relationship satisfaction affect female sexual response
DSM-5 definition of sexual dysfunction
clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure
minimum duration of 6 months
symptoms must cause significant distress
experienced on almost all or all occasions of sexual activity (75% - 100%)
important to consider cultural values & age
DSM-5 sexual dysfunction specifiers
- Nature of the onset: lifelong or acquired
- Context: generalized or situational
- Severity: mild, moderate, severe - based on level of distress (Premature ejaculation is specified by time it takes to ejaculate)
DSM-5 gender specific dysfunctions
male
1) desire:
- male hypoactive sexual desire disorder
2) arousal:
- erectile disorder
3) orgasm:
- delayed ejaculation
- premature ejaculation
female
1) desire and arousal:
- female sexual interest/arousal disorder
2) orgasm:
- female orgasmic diorder
3) pain:
- genito-pelvic pain/penetration disorder
sexual desire disorders
persistent disinterest in sexual activity
the person is distressed by their lack of interest
prevalence 7-33%
aus men 8% vs women 55%
most common female sexual dysfunction
male vs female sexual desire disorders
male hypoactive sexual desire disorder:
- lack of interest in sex, little sexual activity and fantasising
- physical response may be normal
female sexual interest/arousal disorder:
- interest/Desire: A lack of, or significantly reduced, sexual interest in sexual activity and fantasising
- arousal: difficulty attaining or maintaining adequate lubrication until completion of the sexual act
- prevalence rates: uncertain due to high overlap with other female sexual disorders (~30-50%)
- less research focused on females (much more research on males – erectile disorder especially)
erectile disorder
- marked difficulty in obtaining or maintaining an erection until completion of sexual activity, or marked decrease in erectile rigidity
- often spontaneously remits
- up to 50% adult men have erectile difficulty during intercourse at least some of the times
- steep age-related increase of ED
psychogenic vs organic ED
often sudden onset vs gradual onset/deterioration
situational vs always
preservation of morning erections vs decrease in morning erections
erection with masturbation vs no erections with masturbation
psychogenic ED:
- maybe partner-specific
- younger patient (<40)
- other psychological problems
- abnormal sex development
organic ED:
- +/- loss of libido
- chronic medical illness
- pelvis trauma/surgery
- endocrine/neurological disease
- recreational drugs
- +/- reduced size of penis
male orgasmic disorders
delayed ejaculation
- Maintains erection, but marked delay (or inability) to achieve ejaculation, without the person desiring delay
- Experienced on almost all or all occasions of partnered sexual activity
- “thrusting is a chore, rather than a pleasure”
- Prevalence (Au): 4% - the least common male sexual complaint
premature ejaculation
- Ejaculation with only minimal stimulation (less than 1min after vaginal penetration) and before the man wishes it
- Prevalence (Au): 8%
female orgasmic disorder
-Marked delay in, marked infrequency of, and/or absence of orgasm, OR markedly reduced intensity of orgasmic sensations
-If orgasm achieved with clitorial stimulation but not penetration
=> does not meet criteria
- Woman must be clinically distressed about these symptoms
- Lifelong vs. acquired; can be situational
- Orgasm is a learned (not an automatic) response => improves with experience
- prevalence (Au): 51%
genito-pelvic pain/penetration disorder
Persistent or recurrent difficulties in any one of the following:
- Vaginal penetration during intercourse;
- Marked vulvovaginal or pelvic plain during vaginal intercourse or penetration attempts;
- Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation, or during, or as a result of vaginal penetration;
- Marked tensing or tightening of the pelvic floor muscles resulting during attempted vaginal penetration.
- Important to take a detailed history
cycle of pain
body anticipates pain, fear/anxiety
- > body automatically tightens vaginal muscles
- > tightness makes sex painful, penetration may be impossible
- > pain reinforces/intensifies
- > body reacts by bracing
- > avoidance of intimacy
- > anticipates pain…
aetiology of sexual dysfunction
biological/physical:
-aging, disability, illness, medications, substance use
psychosocial:
- cultural/religion
- self-acceptance (identity, orientations)
- body image
- anxiety, depression
- life stressors
- past experience (abuse, trauma)
- inexperience
- perfectionism, performance anxiety
environmental:
-lack of privacy, lack of time, physical discomfort
interpersonal:
- attraction to partner
- partner performance
- excessive goal orientation
- relationship quality, conflict
- routinisation, change in roles
- lack of partner
medical treatment for ED
pharmacotherapy:
- viagra, cialis, levitra
- highly effective (70-90%)
- dose modifications may be necessary over time
- increased satisfaction in both men and women
penile injections:
- injections of smooth muscle relaxing drugs into erection chambers
- erection: 30-45 mins
vacuum devices:
- erection limited to 30 min
- 80-90% but high drop out rate
- complications: coolness, numbness, pain with ejaculation
penile prosthesis:
- last resort treatment
- minimal complications (<5%), high satisfaction rate
Important to promote sexual intimacy despite functional challenges
pharmacological treatment for female sexual dysfunction
Pharmacological interventions / medication:
• Hormonal therapy: vaginal or systemic oestrogen & androgen
• Addyi: oral medication for low sexual desire in premenopausal women
• approved in 2015
• effective for a small group of women
• potentially serious side effects: low blood pressure, dizziness and fainting, particularly if mixed with alcohol
Medical treatments need to be offered in the context of a holistic care accounting for subjective and relationship experiences
non-pharmacological treatments for female sexual dysfunction
genito-pelvic pain/penetration disorder:
Kegel exercises and vaginal weights
- aimed at strengthening the muscle of the pelvic floor
Vaginal lubricants
- usually a liquid/gel that is applied around the clitoris, labia and inside the vaginal entrance to minimise dryness and/or pain during sexual activity
Vaginal moisturisers
- non-hormonal products
- improve overall vaginal health by restoring lubrication and the natural pH level to the vagina and vulva
Vaginal dilators
- Plastic/rubber tube used to stretch the vagina
- To treat vaginismus & dyspareunia
female sexual arousal disorder:
Eros ctd: Female vacuum therapy
• FDA-approved; requires prescription
• Creates gentle suction over the clitoris to cause engorgement
• Improves vaginal blood flow and lubrication
• Billups et al. (2011, n=32): improved response in sensation, lubrication, orgasm, and satisfaction.
sensate focus exercises
A graded series of mutual body-touching excercises:
- Exercise I: general body pleasuring => focus on sensation of touching partner
- Exercise II: introducing genital body pleasuring in the absence of intercourse
Non-goal-oriented physical intimacy (incl. orgasm) => to minimize ‘performance’ pressure/anxiety and reduce ‘spectatoring’
Enhancing communication between partners about sensual and sexual experiences
Effective in treating female desire, arousal & orgasmic dysfunctions and erectile disorders
barriers to treatment uptake and retention
Patients are unaware of available resources
Lack of referral
Embarrassment (patients and/or GP providers)
Lack of engagement (either or both partners)
Minimal attention to partners (not included or assessed)
limitations to treatment research
Inadequate research methodology
Limited treatment focus: commonly do not work from a bio-psycho-social perspective
Small number of studies
