Sexual Dysfunctions & Paraphilias – Comprehensive Study Notes
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- Psychiatry divides sexual topics into: normal sexuality, sexual dysfunctions, paraphilias, and gender dysphoria.
- Two disorder clusters covered here: sexual dysfunctions (failures in normal response) vs. paraphilias (atypical, often illegal urges).
- Sexual dysfunction = inability to respond to stimulation or painful sex; ICD-10: inability “to participate in a sexual relationship as he or she would wish”.
- DSM-5 list begins: male hypoactive sexual desire disorder …
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- Full DSM-5 list: male hypoactive desire, female sexual interest/arousal, erectile, female orgasmic, delayed ejaculation, premature ejaculation, genito-pelvic pain/penetration, substance/med-induced, other/unspecified.
- Specify: lifelong vs. acquired, generalized vs. situational, etiology (psychologic, physiologic, mixed).
- Rule-out: if entirely med/substance, code “due to GMC” or “substance-induced”.
- Severity coded by patient distress \text{(mild\;|\;moderate\;|\;severe)}.
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- Male hypoactive sexual desire = \leq sexual thoughts/desire \geq 6\text{ mo}.
- Prevalence low overall \approx 2\% ages 16–44, increases to 40\% age 66–74.
- Causes: defensive inhibition, hostility to partner, poor self-esteem, health, meds, stress.
- Diagnostic pearl: only pathologic if distressing to patient.
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- Sex-history outline (Table 16-1) begins: ID data—age, sex, occupation, relationship status, orientation.
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- Current functioning: satisfaction level, specific dysfunctions, onset (lifelong vs. acquired), generalized vs. situational, frequency, libido rating, script of typical encounter, compulsivity screen.
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- Childhood section: parental attitudes, nudity rules, sex education sources, early self-stimulation, play “doctor,” reactions/punishment.
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- Adolescence: puberty timing, body-image, masturbation pattern, dating history, petting, first orgasm, first coitus, contraception.
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- Adult: premarital experiences, contraception, cohabitation, marriage specifics (honeymoon, pregnancy impact, affairs, pornography, conflict areas).
- Special issues: rape, incest, abuse, STDs, fertility, pregnancies, gender issues, paraphilias.
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- DSM vs. ICD comparison table for Male Hypoactive Desire: \geq 6\text{ mo}, distress, specify generalized/situational, mild–severe, lifelong/acquired.
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- Table 16-3 Female Sexual Interest/Arousal Disorder: need \geq 3 symptoms most encounters \geq 6\text{ mo}; similar specifiers.
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- Conceptual change: desire & arousal merged for women (non-linear response, especially long-term couples).
- Lab-correlates: testosterone ↓, estrogen ↓, prolactin ↑, thyroxin ↑.
- Anticholinergic & antihistaminic meds → lubrication ↓.
- Relationship discord common etiology.
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- Male Erectile Disorder (ED): derogatory term “impotence” dropped.
- Types: lifelong, acquired, situational.
- Prevalence acquired 10–20\%; chief complaint >50\% of treated men; lifelong rare \approx1\% <35.
- Red flags organic after 50 yrs; spontaneous or morning erections suggest psychogenic.
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- Table 16-4 parallels ED criteria; ICD lumps male ED w/ female arousal disorder.
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- Performance anxiety cycle: episodes reinforce fear; anger/communication issues with partner contribute.
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- Case vignette “Mr Y” – erectile dysfunction, sadistic fantasies, marital avoidance; illustrates psychodynamic conflict.
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- Female Orgasmic Disorder: recurrent delay/absence post adequate arousal; some women not distressed.
- Lifelong vs. acquired; masturbation orgasms easier than partnered.
- Prevalence overall \approx30\%; heritability 34–45\%.
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- Psychologic factors: pregnancy fear, vagina damage fear, hostility, guilt, loss-of-control anxiety, cultural inhibition; somatic complaints may mimic.
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- Delayed Ejaculation: difficulty climaxing with partner \geq 6\text{ mo}.
- Prevalence \approx5\%; ↑ with SSRI use & high-stimulation internet porn.
- Severe psychopathology; OCD, ADHD, hostility themes.
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- Case vignette: man only ejaculated with two women or cocaine, anger issues, narcissism → combined therapy.
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- Premature Ejaculation (PE): DSM timing \leq1\text{ min} vaginal penetration; specifiers mild 30–60\text{ s}, moderate 15–30\text{ s}, severe <15\text{ s}.
- Prevalence new criteria 1–3\%; physiologic vs. conditioned subtypes; partner/relationship factors.
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- Female premature orgasm data sparse; rare epileptogenic focus or SSRI-induced spontaneous orgasms.
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- Orgasmic Anhedonia: physical ejaculation w/o pleasure; must rule out lesions; often severe guilt → dissociation; code “other specified sexual dysfunction”.
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- Genito-Pelvic Pain/Penetration Disorder (GPPPD) combines prior dyspareunia & vaginismus; any combo of: penetration difficulty, pain, fear, pelvic floor tension.
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- Dyspareunia: \approx5\% women; hormonal post-menopause ↑; history sexual trauma common; postpartum transient.
- Vaginismus: involuntary outer-third spasm; may be complete; strict religion, abuse, medical trauma etiologies.
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- Case “Miss B” lifelong GPPPD; fear of penetration; orgasmic via non-coital stimulation.
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- Table 16-8 DSM criteria & specifiers for GPPPD.
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- Post-coital headache: throbbing occipital/frontal; vascular/tension; classify as “other specified”.
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- Sexual Dysfunction due to GMC: 20–50\% ED organic; age >60; tests: nocturnal tumescence, Doppler, hormone panels, invasive studies for surgery candidacy.
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- Female dyspareunia organic: surgery 30\% temporary pain; post-menopause mucosa thinning; vestibulitis, interstitial cystitis.
- Female desire/arousal ↓ after illness, surgery, low testosterone.
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- Table 16-9 diseases causing male ED: vascular, neurologic, endocrine, meds, surgery.
- Retrograde ejaculation = organic (post-surgery, anticholinergics).
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- Female orgasmic dysfunction from hypothyroid, DM, hyperprolactin; meds: antihypertensives, stimulants, TCAs, SSRIs, MAOIs.
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- Table 16-10 drugs impairing male function: psychotropics, antihypertensives, abused substances; trazodone risk priapism.
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- Substance/Medication-Induced Dysfunction: pattern relation to intox/withdrawal or med change; nearly any psych med can affect sex; Dopamine ↑ drive; serotonin ↓.
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- Antipsychotics: dopamine blockade → libido ↓, ED, retrograde ejaculation; rare priapism.
- Antidepressants: anticholinergic delays; SSRIs common anorgasmia; cyproheptadine or methylphenidate antidotes.
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- Lithium ↓ hypersexuality; stimulants initially ↑ libido then crash; β-blockers, clonidine, spironolactone, thiazides → ED.
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- Alcohol small doses disinhibit, high doses ↓ erection/testosterone; opioids, hallucinogens, cannabis, barbiturates variable effects.
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- Treatment overview: traditionally psychodynamic; now combine behavioral, pharmacologic, mechanical.
- Pharm for ED: PDE-5 inhibitors (sildenafil etc.), phentolamine, alprostadil injections, MUSE; nitrates contraindicated; NAION rare.
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- Topical vasoactive creams, female arousal agents (phentolamine gel, flibanserin); SSRIs/TCAs useful for PE; topical anesthetic cream.
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- Hormones: testosterone for hypoandrogenism (watch virilization, prostate); estrogen local therapy for atrophy; antiandrogens for compulsive behavior.
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- Mechanical: vacuum pump; EROS clitoral suction; penile prostheses (semi-rigid vs. inflatable); vascular bypass surgery select cases.
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- Dual-Sex Therapy (Masters & Johnson): couple as treatment unit, sensate focus, communication, anxiety reduction; variations with single therapist.
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- Specific techniques: squeeze & stop-start for PE; dilators & physio for vaginismus; masturbation training for anorgasmia; systematic desensitization & mindfulness; group therapy cautions; hypnosis; analytically-oriented sex therapy.
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- Paraphilic Disorders: deviant stimuli required for arousal; DSM-5 disorder only if acted on or distressed \geq 6\text{ mo}.
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- Exhibitionistic Disorder: expose genitals to stranger; almost all male→female; specifiers target prepubertal, mature, or both.
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- Fetishistic Disorder: focus on non-living objects or nongenital parts (partialism); chronic; almost exclusively male.
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- Frotteuristic Disorder: rubbing against non-consenting person (crowds); passive isolated males.
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- Pedophilic Disorder: victim <14, perpetrator \geq16 & 5 yr older; 95 % heterosexual; co-occur with exhibitionism, voyeurism.
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- Sexual Masochism: being humiliated/bound; subtype asphyxiophilia; \approx30\% overlap sadistic fantasies.
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- Sexual Sadism: arousal from suffering of another; can escalate to rape/lust murder; onset before 18.
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- Voyeuristic Disorder: observing unsuspecting naked/sexual persons; first acts in childhood; legal charge loitering.
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- Transvestic Disorder: cross-dressing for arousal; specifiers with fetishism vs. autogynephilia; may progress to gender dysphoria.
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- Other Specified Paraphilias: telephone/computer scatologia, necrophilia, partialism (oralism), zoophilia, coprophilia, urophilia, klismaphilia, hypoxyphilia.
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- Differential: experimentation vs. compulsive pattern; may link w/ schizophrenia or brain disease.
- Prognosis poor if early onset, no guilt, polysubstance, multiple paraphilias.
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- Treatments: external control (prison, supervision), antiandrogens (medroxyprogesterone, cyproterone), SSRIs, CBT (relapse prevention, victim empathy), psychodynamic insight.
- Good predictors: single paraphilia, normal IQ, no substances, good adult attachment.
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- Epidemiology: rare but repetitive; pedophilia most common legal case; 10–20\% children molested; paraphilia onset
- Table 16-23 median acts: exhibitionism 50 acts/patient, voyeurism 17 etc.
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- Etiology: childhood conditioning, abuse, modeling; psychoanalytic failure of castration/separation anxiety coping; biologic abnormalities (hormones, EEG, chromosomes) in clinical samples.
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- Sex Addiction / Compulsivity: not DSM diagnosis; pattern of out-of-control sex seeking, tolerance, withdrawal-like dysphoria; Table 16-24 signs.
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- Comorbidity high: substance use \leq80\%, mood/anxiety.
- Treatment: 12-step (SA, SLAA, SAA), inpatient if danger, SSRIs for compulsive masturbation, medroxyprogesterone ↓ libido, psychotherapy, couples work.
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- Normal Sexuality: interplay anatomy, physiology, culture; healthy sex = pleasurable, consensual, non-compulsive.
- Childhood sexuality recognized (Freud); parental handling differs by sex; critical periods for bonding.
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- Four psychosexual factors: sexual identity (biologic), gender identity (felt), sexual orientation, sexual behavior.
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- Embryology: default female; SRY, SOX9 → testes; androgen exposure weeks 6–12; disorders of sex development (Table 16-25 list: CAH, Turner XO, Klinefelter XXY, AIS, enzyme defects, hermaphroditism).
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- Gender identity usually fixed by 2–3 yrs; gender role learned via reinforcement; incongruence may occur.
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- Sexual orientation categories; mention asexual, polysexual; biology vs. environment debate.
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- Brain regions: orbitofrontal, anterior cingulate, caudate active during arousal; limbic septum & preoptic area erections; serotonin inhibition.
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- Spinal cord reflex centers; penile/clitoral afferents via pudendal nerves.
- Masters & Johnson cycle: excitement, plateau, orgasm, resolution; vasocongestion & myotonia key.
- Male & female tables (16-26, 16-27) list specifics; figures show variability.
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- Hormones: dopamine, testosterone ↑ desire; serotonin, progesterone, cortisol ↓; oxytocin spikes with orgasm.
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- Gender differences: men higher baseline desire; women motives include bonding; subjective vs. physiologic arousal mismatch in women.
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- Masturbation universal; infants self-stimulate \approx15–19 months; adolescents use to relieve tension and script adult roles; no evidence causes illness; caution PSA elevation in men.
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- First coitus: rites of passage; cultural myths create performance anxiety; contraception underused first time (only \approx50\% women).
- Elderly sexual activity revived with PDE-5 inhibitors & estrogen creams.
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- End of chapter references (selected key studies on Kinsey, Basson female desire, Bancroft, Carnes sex addiction, etc.).