Psychosexual disorders

Question 1

Define sexual dysfunctions.

Answer 1

Involves problems with libido, arousal, orgasm and ejaculation → distress and/or affecting relationships.

Question 2

Define sexual pain disorders.

Answer 2

Include sexual pain-penetration disorder (SPPD) and dyspareunia.

Question 3

What are symptoms of sexual dysfunctions and sexual pain disorders usually like? When do we consider this diagnosis?

Answer 3

Symptoms may be:

• Lifelong: normal function never experiences or Acquired: normal function lost
• Generalised: normal function is absent or diminished in all circumstances, including masturbation or Situational: normal function is absent or diminished in some circumstances, with some partners, or in response to some stimuli, but not others.

A diagnosis is only considered where symptoms have been present episodically or persistently for at least several months, despite desire for sexual activity and sufficient stimulation and where they cause the person significant distress.

Question 4

How common are symptoms of sexual dysfunctions and sexual pain disorders?

Answer 4

Underreported - studies suggest 40% of adults experience such symptoms.

Women seek out help for hypoactive sexual desire dysfunction and men for erectile dysfunction.

Question 5

Define hypoactive sexual desire dysfunction (HSDD).

Answer 5

HSDD is the absence or significant reduction of sexual desire, evidenced by lack of spontaneous sexual thoughts and fantasies, desire in response to erotic cues and stimulation, or inability to sustain interest in sexual activity after starting.

Question 6

Who is HSDD more common in? What causes it?

Answer 6

More common in women
• Primary = idiopathic

o Can be associated with childhood sexual abuse

• New onset

o Physical illness or injury and its treatment
o Depression, anxiety
o Medication or substance use
o Relationship problems

o Cultural factors

o Lack of knowledge or experience

o Menopause or Childbirth in women

o Low testosterone in men

Question 7

How do we manage HSDD/low libido?

Answer 7

Establish there are no physical health problems

Treatment is mainly psychological

Communication is encouraged

Tailored sexual education

Sensate Focus Therapy

o Intercourse is initially banned
o Non-genital caressing (focus on pleasure and relaxation)
o Genital touching to achieve arousal and subsequent orgasm

o In time, intercourse occurs naturally

Timetabling Sex
o Helps partners with different libidos reach a compromise

Open communication between partners encouraged.

Question 8

Define compulsive sexual behaviour disorder.

Answer 8

CSBD is a persistent pattern of uncontrolled intense, repetitive sexual urges resulting in repetitive sexual behaviour over at least 6 months, causing pronounced distress or functional impairment.

Question 9

What are the symptoms of CSBD?

Answer 9

It can have features of:

• salience
• rapid reinstatement after withdrawal
• continuance despite harm which are seen in harmful and dependent substance use, too

Question 10

Who does CSBD commonly affect? What causes it?

Answer 10

It more commonly affects men and can damage relationships.

Psychiatric (e.g. mania, substance use) and organic causes (e.g. frontal lobe syndrome, testosterone or oestrogen use, dopaminergic medication in Parkinson disease) must be investigated.

Question 11

How is CSBD managed?

Answer 11

Rule out psychiatric and organic causes.

CBT-based treatments

Can also use SSRI’s, GnRH therapies and anti-androgens

Question 12

Define female sexual arousal dysfunction (FSAD). What can cause it?

Answer 12

The absence or marked reduction of a woman’s response to sexual stimulation, evidenced by absent/markedly reduced genital responses (e.g. vulvovaginal lubrication), non- genital responses (e.g. increased heart rate), and feelings (excitement and pleasure).

Its aetiology can be organic (e.g. menopausal atrophic vaginitis,infection) or psychological (e.g. anxiety).

Question 13

How do we manage FSAD?

Answer 13

Treatment include lubricating gels, hormone replacement therapy, and psychological therapies.

Question 14

Define erectile dysfunction (ED).

Answer 14

ED is the inability/ very reduced ability to sustain a sufficiently hard or lasting erection for intercourse to occur.

Question 15

What are the causes of ED?

Answer 15

Main causes

o Organic

• Vascular: Diabetes, Arteriosclerosis
• Neurological (autonomic neuropathy, MS, surgical or traumatic nerve injury)
• Pituitary failure, testicular underdevelopment (e.g. Klinerfelter syndrome, mumps virus)
• Iatrogenic: antidepressants, antipsychotics, antihypertensives, beta blockers, diuretics
• Substance misuse especially excessive alcohol (brewers droop)
• Peyronie disease (penile fibrosis)
• Priapism (prolonged erection causing scarring id not treated promptly)

o Psychological

• Relationship problem
• Cultural factors
• Lack of knowledge/Experience
• Depression
• Performance anxiety

In performance anxiety, there are fears of sexual ‘failure’ sometimes caused by a previous failure

Anxiety inhibits erections, triggering a vicious cycle

Question 16

What are the investigations for ED?

Answer 16

Physical examination including genitals (usually normal)

Blood tests

o Testosterone and sex hormones (low T/hyperprolactinaemia)

o CBG + HbA1c (Glucose (DM)), LFTs and yGT (if alcohol use disorder is reported/suspected)

Question 17

What is the management of ED?

Answer 17

• Modifiable Risk Factors
o Stop smoking, exercise, reduce weight and alcohol, stress management

o Treat diabetes, hypertension etc.

o Review medication (e.g. mirtazapine is associated with placebo-level sexual dysfunction whereas SSRIs have a much higher rate)

Psychological Approaches (sensate focus therapy or CBT) - psychosocial causes

Physical Treatments

o Phosphodiesterase-5 inhibitors (e.g. sildenafil (Viagra) )
o Intracavernosal prostaglandin self-injections before intercourse

o Vacuum pumps

Plastic dome and pump placed over the penis creating a vacuum to produce an erection
This is maintained by slipping a tight ring around the base of the penis

o Topical Therapies

o Surgery

Question 18

Define anorgasmia.

Answer 18

Absent, very delayed, or infrequent orgasm experiences or particularly diminished orgasmic sensations in women.

Question 19

What causes anorgasmia?

Answer 19

Causes include:

• neurodegenerative conditions
• medications (including antidepressants)
• alcohol use
• depression
• relationship factors
• cultural factors
• lack of knowledge/ experience
• previous abuse
• lack of connection with partner.

Question 20

How should we manage anorgasmia?

Answer 20

Although some women can achieve orgasm solely through vaginal penetration, many need direct clitoral stimulation.

Education, self-exploration, masturbation, and sensate focus therapy can help, although some people never achieve orgasm.

Question 21

Define male early ejaculation.

Answer 21

Ejaculation occurs before or in a short time after vaginal penetration or other stimulation, with little/no perceived control.

Question 22

Who is male early ejaculation common in/what is it caused by? How can we manage it?

Answer 22

• Common in younger men
• Sometime stone genetic contribution
• May be caused by medication (e.g. antiparkinsonian medictions)
• Prostatitis
• Improves with practice
• Orgasm can be postponed by the stop-start technique (Squeezing glans penis)
• SSRIs can help - have SEs

Question 23

Define male delayed ejaculation.

Answer 23

Inability to achieve ejaculation or excessive or increaseddelay to ejaculation.

Question 24

What is male delayed ejaculation caused by? How can we treat it?

Answer 24

Can be caused by physical (e.g.antidepressants) or psychological factors (e.g. anxiety).

Treatment includes psychological therapies, advice on varying sexual techniques, and medication review

Question 25

What are the features of sexual pain-penetration disorder (SPPD)?

Answer 25

SPPD (older name: vaginismus) features at least one of:

• Significant difficulty attaining penetration, due in part to involuntary tightening of pelvic floor muscles.
• Marked pelvic pain during penetration.
• Fear of vulvovaginal or pelvic pain before, during, orafter intercourse.

Question 26

What causes SPPD? How can we manage them?

Answer 26

Symptoms can’t be fully explained by an organic condition, mental health disorder, inadequate lubrication, or age- related changes.

Sexual anxiety, previous sexual assault, or abuse sometimes contribute.

Treatment involves education, relaxation, self-exploration, and pelvic floor exercises.

Women can insert vaginal ‘trainers’ (plastic, tampon-like objects) of increasing sizes to getused to penetration.

Question 27

Define dyspareunia.

Answer 27

Recurrent genital pain before, during, or after inter-course with an identifiable organic cause, such as:

• Women— infection, episiotomy, endometriosis,tumour, vaginal dryness.
• Men— urethritis, prostatitis

Question 28

Define vulvodynia.

Answer 28

Medically unexplained chronic pain, burning, or rawness of vulval skin.

Question 29

Define vestibulodynia.

Answer 29

Causes localized redness and tenderness, in response to touch; it usually presents in younger women and is associated with secondary dyspareunia

Question 30

Define Dysaesthetic vulvodynia

Answer 30

Dysaesthetic vulvodynia causes spon-taneous, diffuse pain independent of touch, usually seenin postmenopausal women who aren’t sexually active.

Question 31

Define Dysaesthetic vulvodynia

Question 32

What is the management of vulvodynia.

Answer 32

Treatments include minimizing irritation (e.g. cotton underwear, fragrance-free products, cooling), gentle sexual positions, anaesthetic gels, and stress reduction

Question 33

Define paraphilic disorders.

Answer 33

Persistent, intense patterns of atypical sexual arousalare evidenced by sexual thoughts, fantasies, urges, orbehaviours focused on individuals whose age or statusmakes them unwilling or unable to consent.

Paraphilic disorders are only diagnosed if the person has acted on their desires or are very distressed by them; they affect men more than women

Question 34

In paraphilic disorders, what is sexual arousal triggered by?

Answer 34

Sexual arousal is triggered byatypical stimuli:

• Paedophilic disorder: prepubertal children.
• Coercive sexual sadism disorder: inflicting physical/ psychological suffering on a non-consenting person.
• Exhibitionistic disorder: exposing one’s genitals to an unsuspecting person in a public place.
• Frotteuristic disorder: touching or rubbing against a non-consenting person in crowded public places.
• Voyeuristic disorder: observing an unsuspecting person who is naked, getting undressed, or engaging in sexual activity.
• Other paraphilic disorder involving non-consenting individuals: includes animals (bestiality) and corpses (necrophilia)

Question 35

How can we manage paraphilic disorders

Answer 35

Unwanted arousal may be extinguished by covert sensi-tization: learning to pair arousal with aversive images.

During treatment, the person avoids activities which reinforce their paraphilia, e.g. fantasizing, viewing related pornography.

Antiandrogen medications maybe used in severe or dangerous situations but rely onthe person’s motivation and cooperation, outside of aforensic setting

Question 36

What are gender and sexuality terminology?

Answer 36

Question 37

Define gender:

• identity
• dysphoria
• incongruence

Answer 37

• Gender identity: how you experience your own gender.
• Gender dysphoria: unhappiness/ discomfort aboutyour assigned gender.
• Gender incongruence: persistent incompatibility between your gender identity and the gender you were assigned at birth. You may identify as transgender.

Question 38

Define trans-

• -sexual
• -vestism

Answer 38

• ‘Transsexual’: an older term previously used for transgender people living as a member of the opposite sex, usually after receiving medical intervention(hormones, surgery).
• Transvestism: dressing/ acting in a way traditionally associated with the opposite sex, e.g. for cultural reasons, to express gender identity, or to experience another gender identity (dual-role transvestism). Cross-dressing for sexual arousal is transvestic fetishism.

Question 39

Who experiences gender incongruence? When is it likely to be diagnosed?

Answer 39

Gender incongruence is commoner in people assigned male at birth and usually starts before puberty, although it’s only diagnosed in childhood after at least 2 years of symptoms.

Question 40

How do patients with gender incongruence present?

Answer 40

Children engage in make-believe and play with toys, games, activities, and playmates typical of their experienced gender.

Adolescents and adults experience at least two of:

• A strong dislike/ discomfort with their primary or secondary sexual characteristics due to incongruity with their experienced gender.
• A strong desire to lose some or all of these.
• A strong desire to gain the primary and/ or secondary sexual characteristics of their experienced gender.

People with gender incongruence may seek help for associated distress or mental health problems (e.g.depression), sexual dysfunction, or gender reassignment.

Question 41

How should you manage gender incongruence?

Answer 41

Treatment options include hormone therapy and gender reassignment surgery, following careful joint assessment by psychiatrists, surgeons and other specialists.

The person must live in their experienced genderfor an extended period before surgery is considered

Question 42

What is the prognosis of psychosexual disorders?

Answer 42

Many conditions related to sexual health respond well to therapy, although HSDD is difficult to treat and paraphilic disorders may show little improvement.

Hormonal treatment for gender incongruencecan improve well- being and quality of life, whilesurgery is associated with improved well- being andsexual functioning.

Psychiatric morbidity, suicide, and overall mortality are elevated in transgender people, whether or not they’ve undergone surgical reassignment