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
