SEXUAL DYSFUNCTIONS.pptx

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SEXUAL
DYSFUNCTIONS
Thomas Owondo
Bwindi Community Hospital
© 2017 Thomas Owondo. All rights reserved.

Sexual Dysfunction Defined
• The inability to participate in a sexual relationship as one
wishes.
• Sexual problems that are personally distressing,
persistent, and recurrent.
• Four main categories of disorders:
1. Sexual desire
2. Sexual arousal
3. Orgasm
4. Sexual pain
© 2017 Thomas Owondo. All rights reserved. 2

Sexual Dysfunction Defined
• Subtypes:
 Lifelong vs. acquired.
 Life Long sexual disorder: a sexual disorder that has been present since the
person began functioning.
 Acquired sexual disorder: sexual disorder that develops after a period of normal
functioning.
 Generalized vs. specific/Situational.
 Situational sexual disorder: a sexual disorder that a person has in some situation
but not in others. (i.e. with partner or different lover, in a house or on a beach)
happen with partners of both sex.
 Generalized, meaning they may be a general attitude toward any potential
partner or situation.
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DSM-5 Revisions: An Overview
• Addition of severity and duration (6 months) criteria for
all sexual disorders
• Eliminated Sexual Aversion disorder
• Newly combined disorders:
 Hyposexual sexual desire disorder in women and female
sexual arousal disorder  female sexual interest/arousal
disorder
 Dyspareunia and vaginismus  genito-pelvic
pain/penetration disorder
• Name changes for:
 Male orgasmic disorder (now delayed ejaculation)
 Premature ejaculation (now early ejaculation)

Types of Sexual Dysfunctions
DSM proposes four categories
• Sexual desire disorders
 Lack of interest in sex.
 Includes; Hypersexual disorder and hypoactive sexual desire disorder.
• Sexual arousal disorders
 Failure to become adequately sexually aroused to engage in or sustain sexual
intercourse
 Includes; Erectile dysfunction and female sexual arousal disorder.
• Orgasmic disorders
 Difficulty reaching orgasm or reaching orgasms more rapidly than one would like.
 Includes; Early ejaculation, Delayed ejaculation and Female orgasm disorder.
• Sexual pain disorders
 Persistent or recurrent experience of pain during coitus
 Includes; Dyspareunia and vaginismus 5

DSM-5 – Required Factor Checks
• According to the DSM-5, sexual dysfunction requires a person to feel extreme distress
and interpersonal strain for a minimum of 6 months (excluding substance or medication-
induced sexual dysfunction).
• In addition to the lifelong/acquired and generalized/situational subtypes of sexual
dysfunctions, several factors must be considered during the assessment of the sexual
dysfunction:
 1. Partner factors (their sexual problems, their health status)
 2. Relationship factors (poor communication, discrepancies in desire for sexual
activity.
 3. Individual vulnerability factors (poor body image, history of sexual or emotional
abuse)
 4. Cultural or religious factors (inhibitions related to prohibitions against sexual
activity or pleasure; attitudes towards sexuality)
 5. Medical factors relevant to prognosis (Libido, cardiovascular disease, diabetes)

Sexual Desire Disorders
• Hypoactive Sexual Desire Disorder
 Deficiency in, or absence of, sexual fantasies and desire for sexual activity
that causes marked distress or interpersonal difficulty.
• Hypersexual Disorder
 Incessant sexual desire, fantasy, or thoughts that may lead to excessive or
dangerous sexual activity.

Problems with Hypoactive Sexual Desire
• Biological and Psychological Etiological Factors
 Hormone levels: Androgens and estrogens
 Psychotherapeutic drugs and conditions
 Daily hassles and relationship stress/satisfaction
 Negative perceptions of sexuality, history of sexual abuse
• Assessment and Treatment
 A complete sexual, medical, and psychosocial history
 Blood serum tests to evaluate hormone levels
 Testosterone replacement therapy
 Pharmacological treatments (e.g., buproprion, apromorphine)
 Sensate focus therapy
 Identifying distracting thoughts, sexual preferences

Sexual Arousal Disorders
• Erectile Dysfunction (ED)
 The inability to reach or maintain adequate erection of the penis to engage
in intercourse. This includes a decrease in erectile rigidity.
• Female Sexual Arousal Disorder
 Persistent or recurrent inability to attain (or maintain until completion of
sexual activity) an adequate genital lubrication-swelling response of
sexual excitement that causes marked distress or interpersonal difficulties.

Erectile Dysfunction
• DSM Diagnostic Criteria
 Inability to reach/maintain erection or erectile rigidity occurs all or almost all of
the time for at least 6 months
• Biological Etiological Factors
 60%-80% of ED cases are organic in nature.
 Surgery, chronic illnesses and vascular disorders can all interfere with the normal
blood inflow to the corpora cavernous (erectile tissue in the penis)
 Drugs that reduce testosterone, increase dopamine, or interfere with the
increase in parasympathetic activity that facilitates penile smooth muscle
relaxation required for erection

Erectile Dysfunction (cont.)
• Psychological Etiological Factors
 Anxiety
 Negative Expectations
 Spectatoring: Focus on performance instead of pleasure
• Assessment
 Identifying situations and beliefs surrounding ED onset
 Measurements of genital blood inflow and outflow, nocturnal erections, free and
bioavailable serum testosterone
• Treatment
 Vacuum and constriction devices, penile implants
 Pharmacotherapy (e.g., injections, creams, Viagra)

Female Sexual Arousal Difficulties
• DSM Diagnostic Criteria and Prevalence
 Persistent, recurrent inability to attain or maintain genital response to sexual
excitement, which causes marked distress or interpersonal difficulty and lasts for
at least 6 months
 Some issues with a sole focus on genital response in criteria
 20% estimated lifetime prevalence of related problems
 Estrogen and androgen levels
 Sympathetic and parasympathetic nervous system integrity
 General mood and feelings about one’s body
 Feeling desired by a partner
 Worry about the consequences of sexual behavior

Female Sexual Arousal (cont.)
A comprehensive review of an individual’s sexual, medical and
psychosocial history, as is done for HSDD in women
Topical lubricants
Vasodilator drugs
EROS clitoral therapy device

Orgasm Disorders
• Delayed Ejaculation
 Delayed or inhibited ejaculation following normal sexual arousal and
adequate sexual stimulation.
• Early Ejaculation
 Ejaculation that occurs with limited stimulation before, or shortly after,
penetration and sooner than the man desires
• Female Orgasm Disorder (FOD)
 The persistent or recurrent delay in, or absence of, orgasm following a
normal sexual excitement phase

Ejaculation Disorders
• DSM Diagnostic Criteria and Prevalence
Delayed:
• Delayed or inhibited ejaculation must occur all the time or most of the
time for at least 6 months
• Affects only 3% of the population, often only affects men during
intercourse
Early:
• Ejaculation occurs with little stimulation and ejaculation latency is lower
than the man desires
• Typically men ejaculate within the first minute of intercourse.

Ejaculation Disorders (cont.)
 Deficiency in the afferent or efferent sympathetic nervous circuits involved in the
ejaculatory process
 Arousability/response to visual stimuli
 Anxiety? Perceived control over ejaculation
Assessment of ejaculation latency, feelings of control over
ejaculation, distress caused by problems
“Squeeze” and “pause” techniques
Couple’s foreplay
Use of topical anesthetics

Female Orgasmic Disorder
• DSM Diagnostic Criteria
 Delay, absence of orgasm during a sexual encounter must be persistent and
recurrent (for ≥ 6 months), and cause marked distress or interpersonal difficulty
 A woman’s orgasmic capacity is less than would be reasonable for her age,
sexual experience, and the adequacy of sexual stimulation she receives

Female Orgasmic Disorder (cont.)
 Impairments in endocrine, nervous system, brain function
 Medical conditions
 Psychotherapeutic drug use
 Sexual guilt, religiosity, sexual inexperience
 Mainly thought to be related to psychological factors
 Comprehensive sexual, medical, and psychosocial history
 Sensate focus, systematic desensitization, sexual education
 Directed masturbation

DSM-5 Genito-pelvic pain/penetration Disorder:
combined dyspareunia and vaginismus
• Dyspareunia
 Persistent and recurrent genital pain during intercourse, or in situations
other than sexual encounters (e.g., gynecological examinations)
• Vaginismus
 Repeated and persistent involuntary spasm of the outer third of the
vaginal muscles that interferes with penetrative intercourse

Dyspareunia
• Characteristics and Prevalence
 Ongoing (≥ 6 months) experiences of sharp, dull, burning or shooting pain in the
vaginal area or other areas of the pelvis
 Shares many characteristics with pain disorder
 Affects up to 16% of U.S. women
• Biological Etiological Factors
 Medical conditions (e.g., injury, urinary tract or yeast infections, endometriosis,
uterine fibroids)
 Provoked Vestibulodynia (PVD): Pain resulting from sensitivity to touch or pressure
of the vulvar vestibule
 Vulvovaginal Atrophy: Deterioration and reduction of lubrication of postmenopausal
vaginal tissue

Dyspareunia (cont.)
• Psychological Etiological Factors
 Fear of pain, anxiety associated with sexual activity
 Negative attitudes, depression
• Assessment
 Description of the location, intensity, quality, duration and time course of pain, as well
as its interference with sexual activity.
 Gynecological, physical therapy exams.
• Treatment
 Cognitive behavioral therapy (CBT)
 Electromyographic feedback
 Vestibulectomy and pelvic floor training
 Postmenopausal estrogen administration

Vaginismus
• Characteristics and Prevalence
 Repeated vaginal spasms that prevent intercourse that persist for at least 6
months
 Highly comorbid with FSAD.
 Affects between 1% to 6% of female adults
 Provoked PVD: Response to anticipated sexual pain
 Anxiety and negative beliefs about sexuality
 History of sexual abuse
 Systematic desensitization

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QUESTIONS

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