Exam 3 Behavior

Sexual identity

Biological sexual characteristics

Gender Identity

Conviction of being male or female

Sexual orientation

Describes the object of a person’s sexual impulses

Criteria for Gender Dysphoria (Children)

A. Marked incongruence between one’s experience/expressed gender and assigned gender; at least 6 months duration with at least 6 of the following:

• Strong desire to be other gender or insistence that one is other gender

• [In those assigned male at birth]- strong preference for cross-dressing or simulating female attire; [In those assigned female at birth]- strong preference for wearing only typically masculine clothing and strong resistance to feminine clothing

• Strong preference fro cross-gender roles in fantasy play

• Strong preference for the toys/games/activities stereotypically used in other gender

• Strong preference for playmates of other gender

• In boys- strong rejection of typically masculine toys/games/activities with avoidance of ‘rough-and-tumble’ play; In girls- strong rejection of typically feminine play

• Strong dislike of one’s sexual anatomy

• Strong desire for the primary/secondary characteristics that match one’s ‘experienced’ gender

B. clinically significant distress or impairment

What duration is needed dx gender dysphoria

6 months

Criteria for Gender Dysphoria (Adolescence / Adult)

A. Marked incongruence between one’s experienced/expressed gender and assigned gender, at least 6 months with at least 2 of the following:

• Marked incongruence between one’s experienced/expressed gender and primary/secondary sex characteristics

• Strong desire to be rid of one’s primary/secondary sex characteristics because of marked incongruence with one’s experience/expressed gender

• Strong desire for primary/secondary sex characteristics of the other gender

• Strong desire to be of the other gender

• Strong desire to be treated as the other gender

• Strong conviction that one has the typical feelings and reactions of the other gender

B. clinically significant distress or impairment

What is the normal gender development in children

2-3 years old: can recognize gender differences

3-5 years old: Will start to play with “gender appropriate toys”

5-6 years old: Will start to spend most of the time playing with children of the same sex

Treatment for Gender Disorders

Individualized approach

Screen for concerns of underlying depression, anxiety, eating disorders, sexual abuse/trauma and treat appropriately

Psychotherapy for patient and family members

Some patients will choose socially transitioning to opposite sex

Some patients will choose medical or surgical interventions

Sexual Disorders

Person’s inability to participate in a sexual relationship that he or she would wish

What needs to be rule out before dx of sexual disorders

an acquired medical condition

use of pharmacological substance that could account for or contribute to the dysfunction

How long must a sexual disorder present to be dx

6 months

Types of Female Sexual Disorder

Genito-Pelvic pain disorder

Female orgasmic disorder

Female sexual interest/arousal disorder

Types of Male Sexual Disorder

Male hypoactive sexual desire disorder

Erectile disorder

Premature ejaculation

Delayed ejaculation

Criteria for Genito-Pelvic Pain Disorder

A. Persistent or recurrent difficulty with one of the following

• Vaginal penetration during intercourse

• Marked vulvovaginal or pelvic pain during intercourse or penetration attempts

• Marked fear/anxiety about vulvovaginal or pelvic pain in anticipation of, during or as a result of vaginal penetration

• Marked tightening or tensing of pelvic floor muscled during attempted penetration

B. persisted for at least six months

C. clinically significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors, and it is not attributable to substance/medication/medical issue

What are the clinical features of genito-pelvic pain

May not be able to insert anything into the vagina

Dyspareunia

Vagismus

May avoid sexual situations out of fear

Relationship strain

Not related to an organic problem or decreased lubrication

Can worsen during post-partum period

Dyspareunia-

recurrent genital pain occurring before, during, or after intercourse

Vagismus-

constriction of the outer third of the vagina due to involuntary pelvic floor muscle tightening

Risk Factors for Genito-Pelvic Pain Disorder

History of sexual and/or physical abuse

Anxiety or guilt about sexual act

Frequently occurring with other mentioned sexual dysfunctions

Treatment for Genito-Pelvic Pain Disorder

Sex therapy

Couples therapy

Individual psychotherapy

Pelvic floor PT

Sex therapy

teach about normal sexual function and cycles, discuss concerns about sexual activity, and offer suggestions and exercises to improve sexual relationships between couples

Criteria for Female Orgasmic Disorder

A. either of the following symptoms and experienced on almost all or all occasions of sexual activity

• Marked delay in, marked infrequency of, or absence of orgasm

• Markedly reduced intensity of orgasmic sensations

B. have persisted for at least six months

C. clinically significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors, and it is not attributable to substance/medication/medical issue

What are the clinical features female orgasmic disorder

Women generally complain more or are more concerned with poor interest/desire/arousal

Cannot achieve orgasm with clitoral manipulation

May still feel satisfied

What is often needed to achieve orgasm in women

Most women need clitoral manipulation during intercourse

Minority of women can have an orgasm with intercourse alone

Primary Female Orgasmic Disorder

never experienced orgasm

Secondary Female Orgasmic Disorder

previously experienced orgasm or can only experience orgasm through masturbation

How does female orgasmic disorder change with age

Many women are able to have more orgasms as they get older

Risk Factors for Female Orgasmic Disorder

Anxiety

Sociocultural factors like gender role expectations

Treatment for Female Orgasmic Disorder

Sex Therapy

Couples Therapy

Psychotherapy

Devices in increase clitoris blood flow (Vibrators / EROS-CTD)

Criteria for Female Hypoactive Sexual Desire Disorder-

A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:

• Absent/reduced interest in sexual activity

• Absent/reduced sexual/erotic thoughts or fantasies

• No/reduced initiation of sexual activity / unreceptive to a partner’s attempts to initiate

• Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all sexual encounters

• Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues

• Absent/reduced genital or nongenital sensations during sexual activity in almost all or all sexual encounters

B. Duration for 6 months

C. significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors, and it is not attributable to substance/medication/medical issue

What are the clincial features of Female Hypoactive Sexual Desire Disorder

Decreased or lack of sexual feelings, thoughts, desires

Infrequent sexual activity

Difficulty experiencing orgasm

Pain during intercourse

Subjective and objective evidence of arousal may not correlate

What factors should be considered for Female Hypoactive Sexual Desire Disorder

1. Partner factors: partner sexual issues, health

2. Relationship factors: poor communication, discrepancies in desire

3. Individual vulnerability factors, psych issues or stressors: body image, h/o abuse, recent job loss, bereavement

4. Cultural factors

5. Medical factors: general health, aging, medications, menopause

Risk Factors for Female Hypoactive Sexual Desire Disorder

Negative cognitions or attitudes about sexuality

History of mental disorder

History of medical conditions: DM, thyroid dysfunction

Treatment for Female Hypoactive Sexual Desire Disorder

Lifestyle changes

Sex therapy/couples therapy/individual psychotherapy

Medications:

What medications can be given for Female Hypoactive Sexual Desire Disorder

Flibanserin (Addyi)

Bremelanotide (Vylessi)

Buproprion (Wellbutrin) off label

Flibanserin (Addyi)

Selective Serotonin antagonist

Indication for Flibanserin (Addyi)

Female Hypoactive Sexual Desire Disorder in premenopausal women

SE for Flibanserin (Addyi)

hypotension

lightheadedness

syncope

What can increase the side effects of Flibanserin (Addyi)

•alcohol within 2 hours of taking medication

Bremelanotide (Vylessi)

SQ Melanocortin receptor agonist

What is the difference between taking Flibanserin (Addyi) and Bremelanotide (Vylessi)

Flibanserin → PO daily

Bremelanotide → SQ 45 min prior to sexual activity

SE of Bremelanotide (Vylessi)

N/V

Flushing

Headache

HTN

Criteria for Male Hypoactive Sexual Desire Disorder

A. Persistently or recurrently deficient or absent sexual/erotic thoughts or fantasies AND desire for sexual activity

B. persisted for at least 6 months

C. clinically significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to another substance/medication/medical condition 

What are the clinical features of Male Hypoactive Sexual Desire Disorder

Lack of interest in sexual activity or sexual thoughts/fantasies

Should be a source of distress for patient

Risk Factors for Male Hypoactive Sexual Desire Disorder

ETOH

Psychiatric conditions (especially depression and anxiety)

Relationship issues

erectile/ejaculation issues

Treatment for Male Hypoactive Sexual Desire Disorder

Sex therapy/couples therapy/individual psychotherapy

Criteria for Erectile Disorder

A. one of the three following symptoms on almost all or all occasions of sexual activity

• Marked difficulty in obtaining an erection during sexual activity

• Marked difficulty in maintaining an erection until the completion of sexual activity

• Marked decrease in erectile rigidity

B. persisted for at least six months

C. clinically significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to another substance/medication/medical condition

What are the clincial features of Erectile Disorder

Low self esteem/confidence

Decreased sense of masculinity

Fear/avoidance of sexual encounter

How does age effect male erection

Longer refractory period

More direct stimulation needed

Penile rigidity decreases

Longer time to erection

What should be rule out in erectile disorder

Diabetes

Vascular Disease

Pelvic Surgeries / XRT

Medication (Antidepressant / Antipsychotics / Antihypertensive )

What are red flags for erectile disorder > organic cause

Spontaneous erections when not planning on having intercourse?

Morning erections?

Erections during masturbation or partners other than his usual one?

Treatment of Erectile Disorder

Limit stress

Masturbation – increase confidence in abilities

Good sleep, exercise, balanced diet etc.

Individual psychotherapy/couples therpay/sex therapy

Vacuum pumps

Phosphodiesterase-5 (PDE-5) inhibitors

SE of Phosphodiesterase-5 (PDE-5) inhibitors

Hypotension

What medications cannot be taken with Phosphodiesterase-5 (PDE-5) inhibitors

alpha blockers

nitrates

Sildenafil (Viagra

(PDE-5) inhibitors

vardenafil (Levitra),

(PDE-5) inhibitors

tadalafil (Cialis)

(PDE-5) inhibitors

Criteria of Premature Ejaculation

A. persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within one minute following vaginal penetration and before the individual wishes it

B. persisted for at least six months

C. clinically significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to another substance/medication/medical condition

How does premature ejaculation differ from DSM-5 and Urology

DSM-5 → Within one min

Urology → Within two min

What are the clinical features of Premature Ejaculation

Not the same as when a patient or their female partner is concerned because ejaculation occurs prior to female orgasm

Many report feeling a sense of no control over ejaculation

Causes a lot of apprehension, embarrassment about future sexual contact

Most Common Male Sexual Dysfunction

Premature Ejaculation

Risk Factors for Premature Ejaculation

Hyperthyroidism

prostatitis

anxiety disorder– especially social phobia

Treatment for Premature Ejaculation

Psychotherapy

Pharmacotherapy

• SSRI’s

• Topical anesthetics

When are topical anesthesia applied for premature ejaculation

5 min prior

Criteria for Delayed Ejaculation Disorder

A. Either of the following symptoms must be experienced on almost all or all occasions of partnered sexual activity and without the individual desiring delay

1. Marked delay in ejaculation

2. Marked infrequency or absence of ejaculation

B. persisted for at least six months

C. clinically significant distress

D. not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to another substance/medication/medical condition

What are the clinical features of Delayed Ejaculation

Repeated thrusting that results in stopping the activity due to either frustration, exhaustion or partner pain

Rarely present with masturbation

Risk Factors for Delayed Ejaculation

Age Realted (esp > 50)

What factors should be considered for delayed ejaculation

1. Partner factors: partner sexual issues, health

2. Relationship factors: poor communication, discrepancies in desire

3. Individual vulnerability factors, psych issues or stressors: body image, h/o abuse, recent job loss, bereavement

4. Cultural factors

5. Medical factors

Treatmetn for Delayed Ejcaulation

Sex therapy/couples therapy/individual psychotherapy

Paraphilias

Sexual excitement only by unusual or bizarre stimuli

Paraphilic disorder:

paraphilia that causes distress or impairment or involves harm to others

Treatment for Paraphilias

Treat common comorbid conditions

specific behavior modification techniques

May see SSRI/SNRI or Depo-Provera used in treatment of hypersexual states

most common paraphilia

Pedophilia

Pedophilia

Engaging in sexual activity with children of the opposite or same sex

Children must be less than 13 years old; offender must be at least 16 years old and 5 years older than the victim

Voyeruism (aka Scopophila)

Recurrent preoccupation with fantasies and acts that involve observing people who are naked or engaged in grooming or sexual activity

Masturbation usually accompanies or follows the event

Exhibitionism

Exposing genitals to unsuspecting people in a manner that shocks them

Sexual excitement occurs in anticipation of the exposure and orgasm is brought by masturbation during or after the event

Fetishism

Sexual focus is on objects that are intimately associated with the human body

Sexual preference for inanimate objects

Transvestic Fetishism

Source of sexual gratification obtained from wearing women’s clothing, particularly lingerie, as an adjunct to masturbation or coitus

Frotteurism

Sexual gratification is obtained from rubbing the penis against a nonconsenting, unaware woman

Sexual Masochism

recurrent preoccupation with sexual urges involving the act of being humiliated, beaten, bound, or made to suffer

Sexual Sadism

derive pleasure from expressing their aggressive instincts

What races have the highest rates of suicide in the US

American Indian / Alaska Native (#1)

White (#2)

Native Hawaiian / Pacific Islander (#3)

What is the gender difference in suicide

Women are more likely to attempt

Men are more likely to die

Most Common Methods of Suicide in US Adults

Firearm (#1)

Suffociation (Most for children)

Poisoning

What age ranges are most common in suicide

85+ (#1)

75-84 (#2)

35-44 (#3)

Deliberate self-harm/ Parasuicide/ Self-injurious behavior (SIB)

Willful self-inflicting of painful, destructive, or injurious acts without intent to die.

Types of Suicidal ideation

Passive

Active

Passive Suicidal ideation

Wish to be dead

Active Suicidal ideation

Thought of serving as the agent of one’s own death

Suicide attempt

Self-injurious behavior with a nonfatal outcome accompanied by explicit or implicit evidence that the person intended to die

Aborted suicide attempt

Potentially self-injurious behavior with explicit or implicitly evidence that the person intended to die but stopped the attempt before physical damage

Suicide

Self-inflicted death with explicit or implicit evidence that the person intended to die.

Risk Factors for Suicide

History of suicide attempt (#1)

Psychiatric disorders

Substance use

Medications

Age, sex, race

Marital status

Occupation

Military service

Adverse childhood experiences

Family history

Medical illness

What medications have been linked to suicidial behavior

Antidepressants

Glucocorticoids

Anticonvulsants

Tramadol (Ultram)

Varenicline (Chantix)

Isotretinoin (Accutane)

Montelukast (Singulair)

What anticonvuslants are linked to sucidiality

Gabapentin

Lamotrigine

Oxcarbazepine

Tiagabien

what professions are considered high risk for suicide

First responders (police, fire, EMS)

Military

Doctors/dentists

What are protective factors for suicide

Social support and family connectedness

Pregnancy and parenthood

Religiosity and participating in religious activities

What are myths about suicide

Asking about suicide will put the thought into their head

If someone is suicidal, they will do it no matter what you do.

If someone is going to do it, they are not going to tell you

If you stop someone from killing themselves, they will just find another way.

Columbia Suicide Severity Rating Scale (CSSRS)

An assessment tool that can be universally used to evaluate a patient for suicidal ideation and behavior

Nine Item (PHQ-9)

A depression scale that can indicate sucidiality

Beck Hopelessness Scale

20-item true/false questionnaire that correlates more closely with current suicide attempt than depression severity