sexual dysfunctions, gender dysphoria Flashcards
LET’S TALK ABOUT SEX
Get used to taking a sexual history and talking about sex! Patients will be very sensitive to how you approach it
Learn to talk about sex as easily as talking about someone’s grocery list. If you look anxious, the pt will be anxious
Above all, treat every patient with the respect she/he deserves
SEXUAL DYSFUNCTIONS
“A clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” (DSM V)
Likely have multifactorial causes (stress, performance anxiety, guilt, communication, misinformation)
Must meet criteria of causing subjective, clinically significant distress
R/O medical causes for any of these
Can be strongly affected by medications & now has its own disorder class to reflect this:
- Antipsychotics thru dopamine blocking
- Antidepressants thru serotonergic activity
- Others: Antihypertensives, drugs of abuse, etc
PREVALENCE ESTIMATES FOR MALE/FEMALE SEXUAL DYSFUNCTION
Men Premature ejaculation 27% Delayed ejaculation 10% Erectile dysfunction 10% Male GPPPD 3%
Women
Female sexual interest/arousal disorder 33%
Female orgasmic d/o 25%
Female GPPPD 15%
Female sexual interest/arousal d/o
Sensate focus exercises (feathers, candles, etc. Intimacy w/out the threat of penetration)
Flibanserin (Addyi): must avoid alcohol (↓BP) and risk of syncope
Sildenafil?
Male hypoactive sexual desire d/o RX
Psychotherapy
Testosterone? Bupropion?
Genito-Pelvic Pain/Penetration Disorder (GPPPD)
Genito-Pelvic Pain/Penetration Disorder (GPPPD)
Medical and/or gynecological workup
Psychotherapy
Delayed ejaculation
Sensate focus exercises
Couples therapy
Sildenafil
Erectile disorder
Sensate focus exercises
PDE-5 inhibitors
Vasoactive injections
Vacuum devices
Premature ejaculation
Delay techniques
Couples therapy
Topicals? TCAs?
Female orgasmic d/o
Masturbation
Accessory equipment
Couples therapy
When they come in with a sex issue, what’s the first thing we want to know?
can you achieve an orgasm on your own? If so–> relationship issue, etc.
19yo female complains of intense vaginal pain during intercourse. She is obviously shy and very anxious talking about this and the above sentence is all she’s able to get out without crying.
A) Refer her to ED for urgent eval to r/o Pelvic Inflammatory Dz
B) Refer her for psychotherapy
C) Take a more detailed sexual/medical history
D) Talk to her about sensate focus therapy
E) Refer her to an obstetrician
The answer is C
GENDER DYSPHORIA: Some ground rules
Treat w/same respect you would give to anyone with a culture different from that of your own
Watch the labels (esp “disorder”). No such thing as “gender denial disorder”
Find out what gender pt identifies as & address individual appropriately and consistently
Try very hard not to project your idea of what someone “should” be. If someone has difficulty with how they feel another person should be acting, who does this say more about…?
Remain sensitive that some individuals with GD may have dealt with significant rejection throughout their lives. Social rejection & violence may be primary source of mental distress in these individuals (harassment to the point many attempt suicide)
Genetic sex =
is determined at conception
Fetal androgen (ie, testosterone) must be secreted if a genetic male is then to become phenotypically male
If fetal androgen is somehow present in a genetic female, male genitalia will develop even if ovaries are present
If fetal androgen is missing in a genetic male (or has androgen receptor insensitivity), female genitalia will develop even if testes are present
Gender identity =
is the individual’s perception and self-awareness of being male or female
Gender role =
is the behavior of an individual that identifies him/her as male or female
Sexual orientation =
refers to erotic attraction to males, females, or both. Sexual orientation is not a disorder.
Gender identity development
develops early and is highly resistant to change. This is likely a highly complex process that we know little about
Patients often describe feeling “trapped” in the wrong body
Approx 1/30,000 males and 1/100,000 females seeks sex reassignment surgery
Prevalence: v. difficult….est 0.002%-0.014%?
Estimates of comorbid psychiatric conditions in GD: 61% (Campo, et al, 2003)
Cause?
GENDER DYSPHORIA: Dx criteria needed for all ages:
Marked incongruence between one’s experienced/expressed gender & assigned gender
At least 6 months duration
Can occur with/without a disorder of sex development (congenital adrenal hyperplasia, androgen insensitivity syndrome)
Must cause significant distress or impairment in social/occupational/other functioning
GENDER DYSPHORIA: Children
Strong desire to be of the other gender or insistence that one is a gender other than what has been “assigned” AND
At least 5 of the following strong desires/preferences:
- For attire of the other gender
- For cross-gender roles in play
- For toys/games/activities stereotypically used by other gender
- For playmates of the other gender
- A rejection of assigned-gender toys/games/activities
- Dislike of one’s sexual anatomy
- Desire for primary &/or secondary sex characteristics matching one’s experienced gender
GENDER DYSPHORIA: Treatment in Children
R/O other psychiatric conditions (psychosis, adjustment d/o, etc)
Hormonal/surgical therapy is not appropriate
Tx: Individual and family psychotherapy
Note: According to the American Psychiatric Association (2000), few childhood GD cases will progress with symptoms into adolescence/adulthood. Est. 75% of boys with childhood GD will later report homosexual or bisexual orientation with no corresponding GD
GENDER DYSPHORIA: Adolescents & Adults
At least 2 of the following:
Marked incongruence between experienced/expressed gender and one’s primary &/or secondary sex characteristics
Strong desire to be rid of one’s primary &/or secondary sex characteristics
Strong desire for primary &/or secondary sex characteristics of other gender
Strong desire to be a gender other than assigned gender
Strong desire to be treated as a gender other than assigned gender
Strong conviction that one has typical feelings/reactions of a gender other than assigned gender
GENDER DYSPHORIA: Treatment in Adults/Adolescents
R/O other psychiatric conditions: psychosis, transvestic fetishism, severe personality disorders (esp borderlines w/more generalized identity confusion), homosexuality (esp in adolescents), etc. Obtain collateral information
If reassignment surgery is requested (not all those w/GD will request):
Engage in psychotherapy first:
- Explore pt’s feelings about identity, sexuality, surgery
- Assist in readjustment
- Assist in post-surgical transition if surgery is indicated
Surgery may be indicated if:
- Pt has lived 1-2 yrs in the cross-gender role and begun steps to alter physical appearance (electrolysis, breast binding, dress, etc)
- The next step would then be hormone treatment (estrogens for male, testosterone for women) for approx 1-2 yrs
- If surgery is still desired at this point, male-to-females would undergo a penectomy, orchiectomy, and creation of an artificial vagina; female-to-males would undergo bilateral mastectomy, hysterectomy w/ovaries removed (artificial penises have mixed results)
GENDER DYSPHORIA Treatment Side Effects (Adults/Adolescents)
Most that complete surgery indicate on regular follow-up that they made the correct choice and are happy with their decision
Postsurgical complications can include:
For genetic males: urethral stenosis, misdirected urinary streams, vaginal strictures, and rectovaginal fistulas
For genetic females: chest wall scars and polycystic ovarian dz
Consider side effects of hormone tx:
Estrogen: DVT, ↑ BP, thromboembolic disorders, wt gain, impaired glucose tolerance, liver abnormalities, depression
Testosterone: Impaired liver fxn, acne, Na+ retention edema
GENDER DYSPHORIA and insurance
In 2014, Medicare lifted its three-decade ban on sex reassignment surgery. The ruling “recognizes the procedures are medically necessary for people who don’t identify with their biological sex”
Some Medicaid states such as Oregon, California, Massachusetts, Vermont and Washington, DC now offer medical treatments for gender dysphoria
While it remains to be seen what private insurers will now do, generally Medicare and Medicaid set the trend with insurance coverage. Stay tuned.
22yo male-to-female smoker with a family history of heart disease also has COPD, GERD, and severe eczema. She has been living in a female role for the last 2 years and began taking estrogen 6 mos ago Rx by a doctor in another state but has not had sex reassignment surgery. She says she needs a Rx for estrogen because she just moved here and asks you to please hurry. The first step in management would be :
A) Express concern that the estrogen is causing eczema
B) Urgently ask her if her menses are increased recently
C) Warmly address her and tell her that sex reassignment surgery might be indicated now and advise her to have the surgery before the age of 25
D) Warn her of the dangers of blood clots
E) Ask her to bring a friend or family member to the next visit and you will consider the Rx only with collateral information
answer: D
“LOVE IS A MANY SPLENDORED THING…”
Different strokes for different folks. Remember that the criteria for these involves the causing of distress. If there is no distress or problems, then there may be no “disorder”
Try and leave the judgments at the clinic door. You’re going to meet a lot of people whose values/morals/experiences will differ substantially from your own
You’re going to see a wide expression of human sexuality and some of the issues involved with it. Remember to meet the patient where they are at. Get comfortable with broadening your viewpoint
PARAPHILIC DISORDERS
Duration > 6 months
Intense/persistent sexual interest in something other than a mature, consenting human partner
Requires that the person must experience distress/impairment as a result of the paraphilia or pursuit of the paraphilia has resulted in harm to others.
Prevalence is nearly impossible to determine
Men»_space;» women
Does not always involve a sexual offense
Etiology: ? Theories involve limbic system destruction, seizures, early experiences, Freudian, etc.
PARAPHILIC DISORDERS: DEFINITIONSRequires recurrent, intense sexual arousal from ≥1 of the following:
Exhibitionism: Exposure of genitals to unsuspecting stranger
Transvestic fetishism: Urges/fantasies involving cross-dressing
*** Pedophilia: Urges/fantasies involving prepubescent children “generally ≤13yo” and individual must be at least 16 and >5 yrs older than target
Frotteurism: Touching/rubbing against a nonconsenting person
Voyeurism: Observing an unsuspecting person naked, disrobing, or having sex
Fetishism: Nonliving objects (boots, sex toys, etc)
Partialism: Exclusive focus on one part of body
Telephone scatalogia: Obscene telephone calls
Sexual masochism: Being humiliated, beaten, bound, or otherwise made to suffer
Sexual sadism: Psychological &/or physical suffering of another person
Necrophilia: Contact with corpses
Urophilia: Urine
Zoophilia: Animals
Klismaphilia: Enemas
PARAPHILIC DISORDERS: TREATMENT
Psychotherapy:
Cognitive Behavioral Therapy (CBT)
Aversive conditioning (eg, satiation, flooding)
Biological treatments:
SSRIs (thru manipulation of side effect profile)
Hormonal (usu reserved for pedophilia, sexual sadism, exhibitionism). Medroxyprogesterone or leuprolide –> ↓ testosterone levels –> ↓ sex drive
26yo male is arrested after a long search for a male individual who has been groping females in a crowded downtown NYC office area. Video camera shows him moving freely in the crowd and pushing his body against women in the packed crowd and/or groping them, doing this to as many as 8 or 9 women at a time. He is a successful businessman, has a happy life, and has no criminal record. This is an example of: A) Partialism B) Exhibitionism C) Variant of normal human behavior D) No diagnosis at all E) Frotteurism
The answer is E
