Sexual Dysfunctions + Treatments!

Question 1

What are some psychological, physical, cultural, and social factors that influence the diagnostic processes of sexual dysfunctions

Answer 1

• Relationship factors (i.e. partner violence)
  medical/psychiatric and medical comorbidities
• Is the person functioning in their daily life?
• Cultural or religious factors: a therapist may not be able to suggest masturbation if this contradicts their values and beliefs
• Cultural expectations: our idea about sex as penis and vagina, and our standards for erections may be unrealistic
• Lifestyle factors, overall health

Question 2

Why do we need complex diagnostic processes

Answer 2

• To account for the complexity of sexual function and pleasure
• Accept that etiologies are usually unknown
• Rule out issues that would preclude a diagnosis of sexual dysfunction (i.e. mood disorder can impact sexual dysfunction)

Question 3

What is the definition of a sexual dysfunction

Answer 3

-A clinically significant disturbance in a person’s ability to respond sexually or experience sexual pleasure
-Clinically significant = distress - this is why they are coming to see a physician
-Need to assess levels of distress: mild (1-3), moderate (4-6), severe (7-10)
-Don’t need to diagnose if there is no distress or does not appear to be an issue for the individual; Distress and dysfunction don’t always go together: people can be sexually distressed even without a diagnosable sexual dysfunction

Question 4

How does desire change relative to the partner you are with?

Answer 4

You may have high desire, but when you are with someone who has higher desire, you may experience lower desire because you experience less desire relative to your partner

Question 5

Low Sexual Desire

Answer 5

• Low initiation and receptivity: people may not go out of their way to show sexual cues, or are not receptive to the cues of their partner
• Low sexual desire is common, but diagnoses are not
• It is hard to treat low desire because people may be receptive but not initiating, or visa versa

Question 6

Hypoactive Sexual Desire Disorder (HSDD)

Answer 6

• “desire” dysfunction
• Persistent or recurrently deficient (or absent) sexual erotic thoughts or fantasies and desire for sexual activity (6 months+)
• Only in men

Question 7

Sexual Interest/Arousal Disorder

Answer 7

• Only in women
• “desire” and “arousal” dysfunction
  Need at least 3 of the following of absent/reduced:
• Interest in sexual activity
• Sexual thoughts or fantasies
• Initiation of sexual activity, receptivity
• Sexual excitement/pleasure in 75-100% of sexual encounters
• Sexual interest/arousal in response to sexual cues (internal, external)
• genital/nongenital sensations in 75-100% of sexual encounters

Treatment: PLISSIT, Addyi pill

Question 8

Common risk factors for sexual dysfunctions

Answer 8

• Negative sexual cognitions or attitudes
  past/current history of psychiatric conditions
• Medications (especially for mood disorders)
• Medical conditions
• Partner and relationship factors

Question 9

Erectile Disorder and Treatment

Answer 9

• “arousal” dysfunction

1. Difficulty in obtaining an erection
2. Difficulty in maintaining an erection
3. Decrease in erectile rigidity

Risk Factor:
-Age (especially 50+ years)
- Lifestyle (exercise, smoking)
- other common symptoms

Others: can lead people to get checked out for heart conditions

Treatments:
Pharmacological Treatments: Viagra (lasts 46 hours), Cialis (lasts an entire weekend), Levitra
Injectable Medications: Intracavernosal injections
Medicatied Urethral System
Vacuum erection pumps:

Question 10

Viagra

Answer 10

originally developed for high blood pressure and heart disease; Clinical trials found that it didn’t work for high blood pressure and heart disease, but patients reported having longer and stronger erections, so they shifted to market for this instead

Blocks Enzyme PDE-5 which increases bloodflow to the penis; Sexual stimulation is needed - erections don’t just happen on their own

Take 30 minutes before sex

Question 11

Viagra Side Effects

Answer 11

Erection lasts for 4 hours or longer
Red flush to the face or chest
Headaches due to disregulated bloodflow
Ultravision (blue tinge)
Dizziness
Nasal congestion

Should not take viagra if on meds for a heart condition that have nitrate in them

Question 12

Intracavernosal injections

Answer 12

Injection of vasodilators into the cavernosa in the penis opens up arteries to increase bloodflow in the penis
No sexual stimulation is needed - this induces a purely physiological response
Erections last about an hour

Side Effects:
Numbness of the glans of the penis

Question 13

Medicated Urethral System

Answer 13

A pellet goes into the urethra with an applicator
Penis is massaged to spread the medication around
Effects are localized, just not very effective
1 pellet at a time

Not as effective as injections:
Only at tip of penis, not the shaft
Can cause floopy erections because the base is floopy but the top is erect
Can cause a dull aching pain in the penis

Condom should be used with MUSE - especially if the other partner is pregnant so that the medication is not penetrated into the vulva

Question 14

sexual aversion disorder

Answer 14

It was in the DSM-5 but has since been removed
It is not a general reluctance to have sex, but an intensely negative or fearful response to a specific aspect of sexual interaction
For example, an individual might look forward to having sex until they come into contact with a moustache and then they freeze or shut down. This reaction is often found amongst survivors of sexual trauma

Question 15

Early Ejaculation

Answer 15

Intra-vaginal ejaculatory latency time (IELT), which is within 1 minute of penetration

Recurring pattern of ejaculation occuring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.

If this occurs 75% of the time and for 6 months or longer, and if it causes distress for the individual experiencing the symptoms, then they can be diagnosed with premature (early) ejaculation

factors: Excitement
Frequency (abstaining from ejaculation for a period of time can cause faster ejaculation)
Average time from vaginal penetration to ejaculation in healthy populations is 4-10 minutes

Treatment:
Ejaculate more frequently
Event after ejaculation, you can still continue sexual activities: doesn’t need to stop after ejaculation
Change in positions
Communicate with partner: I’m close, should I delay or keep going?

Squeeze technique: used for early ejaculation; stimulate penis to have an erection and then squeeze the penis
but when the partner senses the ejaculate coming, stop squeezing
This makes the time to ejaculate get longer and longer

Question 16

Delayed ejaculation

Answer 16

Male anorgasmia
- Presence of both a delay in ejaculation and infrequency/absence of ejaculation
- Person must not desire the delay (not a disorder if the delay is not a concern for them)

• with women just “Anorgasmia”: persistent inability to achieve orgasm
• Primary: lifelong; often related to a woman’s lack of knowledge of her own body
  -Secondary: recent onset generally more complex in origin and treatment

Question 17

primary anorgasmia treatment

Answer 17

Psychoeducational counselling and bibliotherapy (offering information on female anatomy, focusing on the importance of clitoral stimulation

Question 18

dyspareunia

Answer 18

Pain during intercourse/pain related to sex
Most literature focuses on women, and it is often overlooked in men

Question 19

causes of genital/pelvic pain

Answer 19

Ovulation
Dermatological conditions
Blisters, genital warts, other STIs
Yeast infection

Question 20

Genito-pelvic pain/penetration (GPPPD)

Answer 20

The muscular component of GPPPD is when the opening of the vagina has an involuntary spasm that tightens and tenses due to the fear of pain on penetration

Vaginal penetration during intercourse
Vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts
fear/anxiety about pain in anticipation of, during, or as a result of vaginal penetration
tensing/tightening of the pelvic floor muscles during attempted vaginal penetration

Treatment: pelvic floor physiotherapy

Question 21

orgasm disorders for men and women

Answer 21

Delayed ejaculation and premature ejaculation for men
Orgasmic disorder for women

Question 22

criteria characterize orgasmic disorder

Answer 22

Presence of either of the following symptoms, experiences on all/almost all occasions of sexual activity
Delay in, infrequency of, or absence of orgasm
Reduced intensity of orgasmic sensations

Question 23

pain disorders for men

Answer 23

(not under the DSM-5)

Penile, testicular, and pelvic pain
Ejaculatory pain without evidence of UTI or other causes
3 months or more
Pelvic floor dysfunction can be a cause

Question 24

vulvodynia

Answer 24

Umbrella term for chronic vulvar pain
3 months of vulvar pain with no identifiable cause

Provoked (when touched) vestibulodynia: Pain during activity involving vaginal penetration (sexual or non-sexual, such as tampon insertion)
Occurs in the vulvar vestibule
Provoked, not constant

Generalized unprovoked vulvodynia: pain over the vulva that is always there
Clitorodynia

Primary: it has been around for as long as you can remember
Secondary: developed later on

Question 25

provoked vestibulodynia (PVD)

Answer 25

Pain during activity involving vaginal penetration (sexual or non-sexual, such as tampon insertion)
Occurs in the vulvar vestibule
Provoked, not constant

Risk factors for PVD
History of repeated yeast infections
Hormones: using hormonal birth control, for example
Vulvar hypersensitivity

Treatment
Therapy targeting pain and sexuality
Pelvic floor phyiso
Surgical
No evidence that medical interventions like creams or botox are effective

Question 26

generalized vulvodynia

Answer 26

Pain over entire area of the vulva that is always there, but can be worsened with sexual activity
Burning discomfort, etc.
Can be treated with tricyclic antidepressants

Question 27

Persistent Genital Arousal Disorder (PGAD)

Answer 27

(not in DSM-5)

feelings of genital arousal feel turned on all the time or most of the time, but the person is not reporting subjective arousal

There are 2 parts of arousal:
1. Sometimes bloodflow in genitals aligns with feeling “turned on” in your head
2. But the opposite can happen as well, where you aren’t feeling turned on psychologically turned on but there is a lot of bloodflow in gential area

Diagnosis: persistent or recurrent: 3 +months, Unwanted or intrusive, distressing sensations of genital arousal

Sensations of genital arousal are not associated with genital pleasure
PGAD is different from hypersexuality

Question 28

PLISSIT model

Answer 28

an approach used to figure out how deep to go and when to stop sex therapy

Permission-Limited Information-Specific Sugguestions-Intensive Therapy

Permission: Permission part of the model involves reassurance that the patient is “normal”
Provides permission to engage in sexual activities, and permission not to as well
The therapist checks in to make sure that their activities are satisfying and consensual
Helps the client navigate their own goals

Limited Information: Sex education
Therapist provides information specific to the concern
Therapist dispels myths and reduces anxiety
Ex. hockey player though he had premature ejaculation, but his teammates were actually using a standard that wasn’t true

Specific Suggestions: When informations is not enough
Specific suggestions are provided based on the client’s goals
Teaches new arousal-enhancing behaviors
Provides homework for clients to practice (Sensate focus; sexy mindfulness: focusing on sensations
Involves touching certain places to see where the pleasure is)

Question 29

sex therapy

Answer 29

Talk therapy that addresses sexual issues and concerns
Many sex therapists start by treating other disorders and as they gain more knowledge in the area of sexuality, they transition to sex therapy specifically

Question 30

sensate focus

Answer 30

Non-genital sensate focus: no genital touch to expand what touches feel good where
Genital sensate focus: breaking old patterns
Penetration without movement: allows penis to be contained without pressure to move and have an orgasm: goal is to maintain an erection but not have an orgasm
Penetration with movement

Question 31

2 main types of self awareness exercises

Answer 31

Stop-start technique: behavioural exercise for people to realize they can regain a lost erection
Involves having a good erection, letting it subside, then stimulating it to come back

Squeeze technique: used for early ejaculation; stimulate penis to have an erection and then squeeze the penis
but when the partner senses the ejaculate coming, stop squeezing
This makes the time to ejaculate get longer and longer

Question 32

pelvic floor physiotherapy

Answer 32

Goal of physio is restore, maintain, and maximize strength, function, movement, and well-being
Typically used to treat incontinence, but is now used for other things including tight pelvic floor muscles, loose pelvic floor muscles, back pain, and other issues
Good for treating GPPPD

Goals:
Improve muscle discrimination and relaxation
Increase elasticity of the vaginal openeing
Desensitize painful areas
Decrease fear of vaginal penetration

Manual techniques: massage, trigger points release, stretching, etc.
Vaginal dilation exercises: stretch and desensitize the vaginal opening, improve muscle control, reduce fear/anxiety related to penetration
Biofeedback: helps normalize muscle activity and improve control of PFMs; uses a range of devices

Question 33

Addyi pill

Answer 33

was originally used for depression, but didn’t seem to work for depression; instead, people reported increased sexual desire
It is a multifunctional serotonin agonist antagonist

side effects:
Dizziness, dry mouth, insomnia etc.

Take one a day every day
Meant to increase excitement about having sex (create subjective feelings of desire)

Three 24-week clinical trials showed that the number of satisfying sexual events increased by 0.5-1/month compared to placebo

Question 34

Vacuum erection pumps

Answer 34

suction draws air out of the chamber and bloodflow is increased
Cap is put on the penis to keep bloodflow there
Side effects: pain