DSA34 - Sexual Dysfunction, Gender Dysphoria, and Paraphilias

When sexual fantasies and the desire for intimacy occur

Define the Desire Phase of Sexual Function

Subjective sense of pleasure and accompanying physiological changes (penile tumescence and erection in men, vasocongestion of pelvis, vaginal lubrication and expansion, and swelling of external genitalia

Define the Excitement Phase of Sexual Function ("Foreplay")

Peaking of sexual pleasure, release of sexual tension and rhythmic contractions of the perineal muscles and reproductive organs (ejaculation in men, and vaginal contractions in women)

Define the Orgasmic Phase of Sexual Function

Muscular relaxation and general well-being

Define the Resolution Phase of Sexual Function

◦What would you like me to know about your sexual practices or preferences in order to best treat you?

◦Do you have any questions or concerns about your sexual safety or choices that I can answer for you?

What open ended initial questions should be asked in Sexual Hx Taking?

◦Are you sexually active?

◦Are you in a monogamous relationship?

◦Do you have a gender preference in partners?

◦Do you consider your sex life to be satisfying overall?

What Sexual Activity questions should be asked in Sexual Hx Taking?

◦Do you consider yourself to have safe sexual practices? What does this look like to you?

◦Do you participate in any sexual activities that you consider risky?

What Sexual Safety questions should be asked in Sexual Hx Taking?

◦Have you ever been tested for sexually transmitted diseases?

◦Have you or any of your partners ever had to be treated for any sexually transmitted diseases?

◦Do you have a preference for testing frequency?

What Infex Hx questions should be asked in Sexual Hx Taking?

◦Are there any aspects of sex that you wish would go smoother?

◦Do you ever feel like you have issues with interest, arousal, or climax?

What Sexual Dysfunction questions should be asked in Sexual Hx Taking?

Delayed Ejaculation

Define Condition:

Time delay, decreased frequency, or even absence of ejaculation --> genital discomfort or exhaustion, avoidance of sexual activity, or guilt/blame

DSM Criteria:

◦Persists for more than 6 months and causes significant social stress

◦Disorder is not due to severe relationship stress, a different sexual disorder, or to the effects of a substance, medication, or medical condition

◦Can be life long or situational

◦Can be generalized or situational

-Tx:

> Referral for Sex Therapy

(NO FDA APPROVED MEDS)

> Amantadine

> Buspirone (anxiolytic - good if co-morbid or anticipatory)

> Cyproheptadine (normally for allergies)

Erectile Disorder

Define Condition:

DSMV Criteria:

At least one of three of the following (all or almost all) for 6 months or more causing significant social distress:

◦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

-Hx:

> Sex for 1st time w/ new partner

> Use of drugs/EtOH

> Lack of sexual desire

> Medical Causes:

>> Acromegaly

>> Addison’s disease

>> Diabetes

>> Hypothyroidism

>> Hyperthyroidism

>> Klinefelter’s syndrome

>> Multiple Sclerosis

>> Dialysis

>> Hypertension

>> Parkinson’s Disease

>> Pelvic surgery or irradiation

>> Peripheral Vascular Disease

>> Pituitary adenoma

>> Spinal cord Injury

>> Syphilis

>> Temporal Lope Epilepsy

>> Cardiovascular disease

-Tx:

> PDE-5 Inhibitors (NO enhancer)

>> S/E = HA, Nausea, Muscle Aches

> Aprostadil (PGE Injex)

Erectile Dysfunction (ED)

Define Condition:

Male is unable to achieve erection

-Hx: Older Men

-Path/Prog:

> Low self-esteem

> Low self-confidence

> Decreased satisfaction

> Reduced sense of masculinity

-Tx:

> CBT (esp if related to Psychosocial stressors)

> PDE-5 inhibitor

Female Orgasmic Disorder

Define Condition:

The experience of orgasm is diminished, delayed or even absent on almost all occasions of sexual activity for at least 6 months

-Tx:

> Orgasm Training

> PDE5 Inhibitors (off-label)

Many women require clitoral stimulation instead of penetration to achieve orgasm

Why might the absence of orgasm during penetration BUT presence of orgasm during clitoral stimulation NOT meet criteria for Female Orgasmic Disorder?

Female Sexual Arousal Disorder

Define Condition:

The partial or complete failure to attain or maintain the lubrication-swelling response characteristic of the excitement phase OR the complete lack of sexual pleasure and excitement

Criteria

The woman has either a lack of interest in sexual activity or arousal as evidenced by at least 3 of 6 symptoms for at least 6 months:

1. Absent/Reduced INTEREST

2. Absent/Reduced SEXUAL/EROTIC THOUGTS or FANTASIES

3. LACK OF INITIATION of sexual activity, and UNRECEPTIVE of partner’s attempts.

4. Absent/Reduced SEXUAL EXCITEMENT/PLEASURE during sexual activity

5. Absent/Reduced SEXUAL INTEREST/AROUSAL in response to any internal or external sexual/erotic cues.

6.Absent/Reduced genital or non-genital sensations during sex

-Hx:

> 1/3 of all married women

> Lack of sexual desire/orgasm

> If Temporary = Stress, No Privacy, No Opportunity

-Tx:

> Bremelanotide (Melanocortin Receptor Agonist)

> Testosterone

> Estrogen (topical or systemic)

Genito-Pelvic Pain Disorder

Define Condition:

Person has pain or discomfort, muscular tightening, or fear about pain when having sexual intercourse (Vaginismus + Dyspareunia)

-Hx:

> Hx of Vaginal Infex

> May be a/w other sexual dysfunctions

> Strict religious practices prior

-Path:

> Feeling of Inadequacy

> Lack of Femininity

> Relationship issues

-Tx:

> Relaxation Skills (learn to reduce muscle tension)

Male Hypoactive Sexual Desire Disorder

Define Condition:

Diminished desire for sexual activity for > 6 months

-Hx:

> May occur w/ erectile issues

-Tx: Testosterone

-Prog: Avoidance or lack of receptiveness to partner

Premature Ejaculation

Define Condition:

Ejaculation within one minute of vaginal penetration for at least 6 months

-Hx:

> May be w/ first encounters, but becomes problems after age 40

> A/w...(temporary w/ these)

>> Hyperthyroidism

>> Prostatits

-Sx: LACK OF CONTROL over ejaculation

-Tx:

> SSRIs (common S/E = ejaculatory delay)

> 1% Dibucaine (applied to coronal ridge and frenulum --> less stimulation = slower ejaculation)

Substance/Medication induced Sexual Dysfunction

Define Condition:

Direct physiological effect from medication or drug of abuse (Interest, arousal, and orgasm can ALL be affected)

> Does NOT occur only in Delirium

> Not better explained by another sexual dysfunction

-Hx: Soon after intoxication, withdrawal or exposure

◦Alcohol

◦Anti-androgens

◦Anticholinergics

◦Antidepressants

◦Antihypertensives

◦Antipsychotics

◦Barbiturates

◦Finasteride

◦Marijuana

◦Opiates

◦Stimulants

"Sensate Focus" (slowly touch the body, working to erogenous regions and slowly progress to intercourse)

What is a non-pharmacological Tx for most sexual dysfunctions?

A term for people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth

Define Transgender

A term for a transgender individual who currently identifies as a man (see also "FTM")

Define Transgender Man

A term for a transgender individual who currently identifies as a woman (see also "MTF")

Define Transgender Woman

A term for people who dress in clothing traditionally or stereotypically worn by the other sex, but who generally have no intent to live full-time as the other gender.

Define Cross-dresser

A term used for people who are born with a reproductive or sexual anatomy and/or chromosome pattern that does not seem to fit typical definitions of male or female

Define Intersex (aka Differences of Sex Development/DSD)

Used to refer to male performers who dress as women for the purpose of entertaining others at bars, clubs, or other events (has been used derogatorily towards transgender women/MTF)

Define Drag Queen

Used to refer to female performers who dress as men for the purposes of entertaining others at bars, clubs, or other events.

Define Drag King

A term used by some individuals who identify as neither entirely male nor entirely female.

Define Genderqueer

A term for individuals whose gender expression is different from societal expectations related to gender

Define Gender Non-Conforming

One who has a significant gender identity that encompasses both genders, male and female - Some may feel that one side or the other is stronger, but both sides are there

Define Bi-gender

A contemporary term that refers to the historical and current First Nations people whose individuals spirits were a blend of male and female spirits (has been reclaimed by some in Native American LGBT communities in order to honor their heritage and provide an alternative to the Western labels of gay, lesbian, bisexual, or transgender)

Define Two-Spirited

The time when a person begins to living as the gender with which they identify rather than the gender they were assigned at birth, which often includes changing one's first name and dressing and grooming differently - may or may not include medical aspects (taking hormones, having surgery, or changing identity documents) and legal aspects (changing identity documents (e.g. driver's license, Social Security record)) to reflect their gender identity

Define Transition

Surgical procedures that change one's body to better reflect a person's gender identity - this may include different procedures, including those sometimes also referred to as "top surgery" (breast augmentation or removal) or "bottom surgery" (altering genitals).

Define Sexual Reassignment Surgery

A person who is attracted to two sexes or two genders, but not necessarily simultaneously or equally

Define Bisexuality (Bi)

A term used to refer to lesbian, gay, bisexual and, often also transgender, people. Some use queer as an alternative to "gay" in an effort to be more inclusive

Define Queer

A person who is fluid in sexual orientation and/or gender or sex identity

Define Pansexual

The practice of having multiple open, honest love relationships

Define Polyamory

Sexually active with only one person

Define Monogamous

Sexually active with multiple people, not necessarily romantic relationships

Define Nonmonogamous

Having no evident sex or sex organs (In usage, may refer to a person who is not sexually active, or not sexually attracted to other people)

Define Asexual

Gender Dysphoria (General)

Define Condition:

DSMV Criteria:

Persistent cross gender identification lasting longer than 6 months in 2 of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experience/expressed gender

3. A strong desire for the primary and/or secondary sex characteristics of the other gender

4. A strong desire to be of the other gender

5. A strong desire to be treated as the other gender

6. A strong conviction that one has the typical feelings and reactions of the other gender.

-Sx: Clinically significant distress or impairment in social, school/occupational, or other areas of important functioning

Gender Dysphoria in CHILDREN

Define Condition:

DSMV Criteria:

Persistent cross gender identification lasting longer than 6 months in 2 of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experience/expressed gender

3. A strong desire for the primary and/or secondary sex characteristics of the other gender

4. A strong desire to be of the other gender

5. A strong desire to be treated as the other gender

6. A strong conviction that one has the typical feelings and reactions of the other gender.

-Hx: Male to Female < 12 y/o = 6:1 to 3:1

> Young Males in CHILDHOOD --> Identify as Homosexual in Adulthood (likely)

> Only 12-27% of children that meet criteria have persistence into late adolescence or adulthood

-Sx: Clinically significant distress or impairment in social, school/occupational, or other areas of important functioning

-Tx:

> Long Term play Therapy

> Family Education

> Social Education

> Advocacy

Gender Dysphoria in Adolescents

Define Condition:

DSMV Criteria:

Persistent cross gender identification lasting longer than 6 months in 2 of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experience/expressed gender

3. A strong desire for the primary and/or secondary sex characteristics of the other gender

4. A strong desire to be of the other gender

5. A strong desire to be treated as the other gender

6. A strong conviction that one has the typical feelings and reactions of the other gender.

-Hx: Male to Female ~ 1:1

-Sx: Clinically significant distress or impairment in social, school/occupational, or other areas of important functioning

> Body Aversion may INCREASE w/ development of secondary sexual characteristics

-Tx:

> Psychotherapy

> Puberty Suppression

> Cross Sex Hormones @ Age 16 y/o

> Sexual Reassignment Surgery @ Age 18 y/o

-Starting at Tanner Stage 2 (from 9-12 y/o); Gives pt more time to explore gender nonconformity & development

-Male Bodied = GnRH analogue to suppress LH (stop Test) & Progestins

-Female Bodied = GnRH analogue to stop Estrogens, Progestin to stop periods

How early can FULLY REVERSIBLE Physical Interventions occur for Transitioning? What does that entail?

> Long lasting, intense gender nonconformity and dysphoria

> Dysphoria emerged or worsened with onset of puberty

> Coexisting psychological, medical, or social problems that could interfere with treatment have been addressed

> Informed consent by adolescent and parents or guardians

What criteria must be met to begin Puberty Suppression?

Age 16 + Informed consent of Adolescent & Preferably parents --> Hormone Therapy

How early can PARTIALLY REVERSIBLE Physical Interventions occur for Transitioning? What does that entail?

> Persistent, well documented gender dysphoria

> Capacity to make a fully informed decision and to consent for treatment

> Age of majority in a given country

> Significant medical or mental health concerns are reasonably well controlled

What criteria must be met to begin Hormone Therapy?

Age 18 w/ informed consent & if lived continuously for 1 year prior

How early can IRREVERSIBLE Physical Interventions (aka SURGERY) occur for Transitioning? What does that entail?

1 Letter listing the following:

◦Persistent, well documented gender dysphoria

◦Capacity for informed consent

◦Age of majority

◦Significant mental or medical health concerns controlled

What criteria must be met to begin Breast/Chest Surgery?

2 Letters listing the following:

◦Persistent, well documented gender dysphoria

◦Capacity for informed consent

◦Age of majority

◦Significant mental or medical health concerns controlled

◦12 months of living in a gender role that is congruent with their gender identity

What criteria must be met to begin Genital Surgery?

-Prolonged Dysphoria

-Contribution to appearance that may provoke abuse and stigmatization

What are the risks of withholding gender affirming Tx?

Paraphilia

Define Sexual Preference:

Sexual preference that is outside of the “normal” sexual desires - BUT DOES NOT CAUSE SOCIAL DISTRESS AND IS CONSENSUAL (Ex: BSDM)

-Hx:

> EtOH or Drug Abuse

> Intimacy issues

> PDs

> Almost always MALE

> Age > 18

> Most are Heterosexual

-Path: Difficulty forming person-to-person sexual relationships or poor self-esteem

-Examples:

> Sexual Masochism

> Sexual Sadism (IF consensual)

> Fetishism

> Transvestic Fetishism

-Tx usually doesn't occur UNLESS forced into it (arrest/discovery by family member):

> 1st = CBT

> Behavioral Therapy (Pavlovian OR Plethysmograph)

> Satiation (Verbal or Masturbatory)

> Covert Sensitization

> Social Skills training

> Aversion Therapy

> Pharm

>> Anti-androgens, Medroxyprogesterone, Leuprolide (lower Testosterone)

>> SSRIs

>> Naltrexone

>> Antipsychotics/Antidepressants (when a/w psych disorder)

Paraphilic Disorder

Define Condition:

Sexual preference that is outside of the “normal” sexual desire - DOES CAUSE SOCIAL DISTRESS AND IS NOT CONSENUAL

-NEVER Safe, Sane and Consensual

-NO RULES

-NEVER Negotiated

-Used to Terrorize, Frighten and Control Victim(s)

-Victim cannot stop abuse

-About Non-consensual power and Control

-Examples:

> Voyeruism

> Exhibitionism (1/3 of sexual offenders)

> Frotteurism

> Sexual Sadism

> Pedophilia

-Tx usually doesn't occur UNLESS forced into it (arrest/discovery by family member):

> 1st = CBT

> Behavioral Therapy (Pavlovian OR Plethysmograph)

> Satiation (Verbal or Masturbatory)

> Covert Sensitization

> Social Skills training

> Aversion Therapy

> Pharm

>> Anti-androgens, Medroxyprogesterone, Leuprolide (lower Testosterone)

>> SSRIs

>> Naltrexone

>> Antipsychotics/Antidepressants (when a/w psych disorder)