Psychosexual Disorders

Question 1

What are the 4 main types of sexual dysfunction?

Answer 1

Problems with:

Sexual drive
Arousal
Orgasm
Pain

Question 2

Identify the common types of problems in each type of sexual dysfunction, differentiating between men and women

Answer 2

Sexual drive

• Male: low libido, hypersexuality
• Female: low libido

Arousal

• Male: erectile dysfunction
• Female: failure of genital response

Orgasm

• Male: premature ejaculation, delayed ejaculation
• Female: anorgasmia

Pain

• Male: dyspareunia
• Female: dyspareunia, vaginismus

Question 3

Give some underlying causes of low libido

Answer 3

- Childhood sexual abuse
New onset may be related to: 
•	Physical illness  
•	Medication  
•	Relationship problems  
•	Childbirth

Question 4

Outline the management for low libido

Answer 4

Treatment is mainly psychological and communication based (sex education if appropriate):

• Sensate Focus Therapy
• Timetabling Sex
o Helps partners with different libidos reach a compromise

Question 5

What are the 4 steps of sensate focus therapy?

Answer 5

1. Intercourse is banned
2. Non-genital caressing (focus on pleasure and relaxation)
3. Genital touching to achieve arousal and subsequent orgasm
4. In time, intercourse occurs naturally

Question 6

Give some underlying causes for hypersexuality

Answer 6

Important to exclude:
• Mania
• Substance misuse
• Organic brain disorders (e.g. frontal lobe syndrome)

Question 7

Outline he management for hypersexuality

Answer 7

• CBT-based treatments

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

Question 8

Give the main organic and psychological causes of erectile dysfunction

Answer 8

Organic
• Diabetes
• Arteriosclerosis
• Neurological (e.g. autonomic neuropathy)
• Pituitary failure
• Medication (antidepressants, antipsychotics, antihypertensives, beta-blockers and diuretics)
• Substance misuse

Psychological
• Depression
• Performance anxiety

Question 9

Differentiate between the clinical features of physical and psychological erectile dysfunction

Answer 9

Age
- Physical: older, psychological: younger

Onset
- Physical: gradual, psychological: sudden

Any erections?
- Physical: no, psychological: yes (early morning, masturbation)

Risk factors
- Physical: smoking, obesity, hypertension, alcohol, psychological: alcohol

Question 10

Outline some investigations for erectile dysfunction

Answer 10

o Physical examination including genitals (usually normal)
o Blood tests
• Testosterone and sex hormone (may see low testosterone/hyperprolactinaemia)
• Glucose (diabetes)
• LFTs/GGT (alcohol misuse)

Question 11

Outline the management of erectile dysfunction

Answer 11

Modifiable Risk Factors
• Stop smoking, exercise, reduce weight and alcohol
• Treat diabetes, hypertension etc.
• Review medication (e.g. changing antidepressant medication to mirtazapine)

Psychological Approaches

Physical Treatments
• Phosphodiesterase-5 inhibitors (e.g. sildenafil (viagra))
• Intracavernosal prostaglandin self-injections before intercourse
• Dome, pump, ring: 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

Question 12

Outline the causes and treatment for a failure of genital response in women

Answer 12

Due to lack of lubrication causing pain on vaginal penetration

Causes: psychological, infection, menopausal atrophic vaginitis

Treatment: psychological approaches, lubricating gels, HRT

Question 13

Outline the management of anorgasmia

Answer 13

o Sex education may resolve anorgasmia if women or their partners are unaware of this (e.g many women need direct clitoral stimulation)
o Self-exploration, masturbation and sensate focus therapy

Question 14

Outline the management of premature ejaculation

Answer 14

o Improves with practice
o Squeezing the glans postpones orgasm
o SSRIs can help

Question 15

Give some causes and management of delayed ejaculation

Answer 15

(Delayed or absent male orgasm)
o Can be physical (e.g. SSRIs) or psychological (e.g. fear of conception)
o TREATMENT: psychotherapy, advice on varying sexual techniques and medication review

Question 16

Give some physical causes of dyspareunia in men and women

Answer 16

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

(Psychological dyspareunia may be due to failure of arousal or due to past abuse/relationship problems)

Question 17

Define vaginismus and outline the treatment

Answer 17

o Painful, involuntary spasm of the vaginal muscles when penetration is attempted
o TREATMENT: education, relaxation, self-exploration (insertion of ‘trainers’) of increasing sizes to become accustomed to penetration

Question 18

Define paraphilias

Answer 18

• Disorders of sexual preference

Occur almost exclusively in men and only require treatment if they cause harm or distress

Question 19

Give examples of paraphilias and its management

Answer 19

• Fetishism: sexual arousal and gratification relies on an object rather than a person (e.g. leather, rubber)
• Paedophilia
• Sadism: inflicting pain causes arousal
• Masochism: humiliation or suffering cause arousal

Management
• Covert sensitisation can prevent unwanted arousal (pairing arousal with aversive images)
• Avoid activities that reinforce the paraphilia (e.g. pornography)
• Anti-androgens may be useful in dangerous situations (e.g. paedophiles who feel that they may be overwhelmed by sexual urges)

Question 20

What are disorders of gender identity and give some treatments

Answer 20

• Transsexual people believe that their gender does not correspond to their body
• They want to live and be accepted as a member of the other sex

Treatments
o Hormone therapy
o Gender reassignment surgery