Sexual Disorders

Overview: Scope & Taxonomy of Sexual Disorders

• Psychiatry divides sexual topics into four pillars:

  • Normal sexuality (development, culture, physiology)

  • Sexual dysfunctions (disturbances of desire, arousal, orgasm or pain)

  • Paraphilic disorders (deviant targets/acts that are illicit, harmful, or compulsory)

  • Gender dysphoria (covered in next chapter)

• Two diagnostic systems used throughout the chapter

  • DSM-5 (American Psychiatric Association)

  • ICD-10 (World Health Organization)

• Key diagnostic rule-outs for every disorder

  • General medical conditions

  • Substance / medication effects (intoxication, withdrawal, chronic use)

  • Other primary psychiatric disorders (e.g., depressive, anxiety, psychotic, personality disorders)

  • Sociocultural factors, relationship problems, age-related changes

Fundamentals of Sexual Dysfunctions (SDs)

• Core definition: Inability to respond to sexual stimulation or presence of pain, lasting \ge 6\,\text{mo}, causing \text{marked distress} or interpersonal difficulty.

• Sub-specifiers (apply to all DSM-5 SDs)

  • Course: \text{lifelong} vs. \text{acquired}

  • Context: \text{generalized} vs. \text{situational}

  • Severity: \text{mild} / \text{moderate} / \text{severe}, based on degree of distress

• High comorbidity with mood, anxiety, personality, schizophrenia; SDs often self-perpetuate → performance anxiety loop.

• Partner reaction cycles: frustration, anger, self-blame; clinician must decide “Which came first—relationship conflict or sexual symptom?”

• Sexual history (Table 16-1) — 7 domains

  1. Identifying data (age, sex, occupation, relationship status, orientation)

  2. Current functioning (satisfaction level, specific dysfunctions, onset, context)

  3. Past sexual history (childhood experiences, parental attitudes, early experimentation)

  4. Adolescence (puberty milestones, masturbation, dating, first orgasm/coitus)

  5. Adult sexual activities (premarital, marital, extramarital, masturbation, pregnancies)

  6. Sex after widowhood/divorce

  7. Special issues (rape, STDs, fertility, paraphilias, gender identity)

Desire / Interest / Arousal Disorders

Male Hypoactive Sexual Desire Disorder (MHSDD) — Table 16-2

• Criterion: \downarrow or absent sexual thoughts/fantasies & desire \ge 6\,\text{mo}.

• Prevalence curves: 2\% (ages 16\text{–}44), 6\% (ages 18\text{–}24), 40\% (ages 66\text{–}74).

• Differential: Decreased activity \neq decreased desire (health, partner unavailability, erectile issues).

• Psychological etiologies: Defensive inhibition, unconscious fears, hostility to partner, deteriorating relationship, low self-esteem.

• Biopsychosocial determinants of desire: Biologic drive + self-valuation + partner availability + good non-sexual relationship.

Female Sexual Interest⁄Arousal Disorder (FSIAD) — Table 16-3

• Combines DSM-IV “desire” + “arousal” reflecting non-linear female response.

• Must have \ge 3 of 6 symptoms (e.g., \downarrow interest, fantasies, initiation, pleasure, cues, genital sensation).

• Discrepancy between genital lubrication and subjective arousal is common.

• Endocrine contributors: testosterone, estrogen, prolactin, thyroxin; antihistaminic/anticholinergic meds ↓ lubrication.

• Marital discord is the single most prevalent etiology in acquired cases.

Erectile Disorder (ED) — Table 16-4

• Lifelong (never penetrated), acquired, or situational.

• Incidence acquired ED: 10\text{–}20\% males; chief complaint in >50\% of male sex-therapy referrals.

• Lifelong rarity: \approx 1\% <35 y.

• Organic vs. psychogenic differentiation

  • Morning erections, solo masturbation, partner-specific success → psychogenic likely.

  • Nocturnal penile tumescence test, Doppler flow, hormonal panel when organic suspected.

• Psychological loops: fear → ED episode → anticipatory anxiety → further ED.

• Case (“Mr Y”): hidden sadistic fantasies, loving behavior → situational ED tied to conflicted masculinity & anger.

Orgasm Disorders

Female Orgasmic Disorder (FOD) — Table 16-5

• Recurrent delay/absence of orgasm after adequate excitement.

• Overall prevalence \approx 30\%; clinic ratio of FOD to other female SDs 4:1.

• Genetics: heritability 34\% (intercourse), 45\% (masturbation).

• Psychodynamics: fear of loss of control, guilt, cultural scripts of “decent women”, body image issues.

• Physical symptoms of frustration: pelvic pain, discharge, irritability.

Delayed Ejaculation (DE) — Table 16-6

• Difficulty or inability to ejaculate during partnered sex despite normal excitation.

• Prevalence \approx 5\%; rising d/t SSRI use & high-stimulation internet pornography.

• Lifelong DE implies severe psychopathology (rigid morals, incest guilt, ADHD distractibility).

• Relationship factors: ambivalence toward pregnancy, anger at partner, OCD comorbidity.

• Case: man ejaculated only with cocaine or two partners; narcissism & anger → required combined psychotherapy + behavioral.

Premature (Early) Ejaculation (PE) — Table 16-7

• Regular ejaculation \le 1\,\text{min} post-penetration.

• Severity specifiers:

  • Mild 30\,\text{s}\text{–}1\,\text{min}

  • Moderate 15\text{–}30\,\text{s}

  • Severe <15\,\text{s} or at initiation

• New strict timing → DSM-5 prevalence 1\text{–}3\%.

• Etiologies: short nerve latency (physiologic) vs. psychogenic (anxiety, conditioning to quick sex — brothel, chance of discovery, dorm room).

Orgasmic Anhedonia

• Physiological ejaculation without subjective pleasure.

• Organic causes: sacral or cephalic lesions; psychiatric: extreme sexual guilt → dissociative split.

Sexual Pain Disorders

Genito-Pelvic Pain⁄Penetration Disorder (GPPPD) — Table 16-8

• Umbrella for former DSM-IV dyspareunia + vaginismus.

• Any combination of difficulty with penetration, pain, fear/anxiety, pelvic floor tension.

Dyspareunia

• Recurrent genital pain \approx 5\% North-American women; ↑ postpartum & menopause.

• Often trauma-linked (rape, CSA).

Vaginismus

• Involuntary spasm of outer \tfrac13 vagina.

• Complete (tampon impossible) vs. partial.

• Correlates: strict religion, sexual trauma, body-integrity anxieties.

• Case (“Miss B”): fear of penetration, orgasmic via manual/oral, dx lifelong GPPPD.

Postcoital Headache

• Throbbing frontal/occipital pain post-orgasm; vascular/ tension / psychogenic; coded “other specified SD”.

Sexual Dysfunction Due to General Medical Condition & Medications

• Male ED organic probability 20\text{–}50\%; >50 y ↑.

• Table 16-9: Diseases: diabetes \approx 2\,000,000 U.S. men impotent, vascular 1.5\,\text{M}, post-surgery 650\,000, etc.

• Pharmacologic culprits (Tables 16-10 & 16-12)

  • Psychotropics: TCAs, MAOIs, SSRIs → \uparrow serotonin \Rightarrow \downarrow libido & orgasm

  • Antipsychotics: dopamine blockade + anticholinergic → ED, retrograde ejaculation, priapism

  • Antihypertensives: \alpha/\beta-blockers, methyldopa, clonidine, diuretics

  • Endocrine drugs, oral contraceptives, anti-androgens

• Neurophysiology (Table 16-11): dopamine ↑ libido; serotonin ↓ libido, delays orgasm; acetylcholine ↑ erection; norepinephrine modulates ejaculation.

• Substance use patterns:

  • Acute low dose → disinhibit; chronic → ED, orgasmic delay, desire ↓ (alcohol, opioids, stimulants, cannabis)

  • Recovery phase often needs therapy to relearn sober sexuality.

Treatment of Sexual Dysfunctions

Somatic Approaches

• PDE-5 inhibitors (sildenafil, tadalafil, vardenafil) — onset \approx 1\,\text{h}, duration \le 4\,\text{h}; contraindicated with nitrates; rare NAION & hearing loss.

• Alprostadil (intracavernosal or intra-urethral), papaverine, phentolamine — local vasodilators; risk priapism.

• Vacuum erection device + constriction ring; EROS (female clitoral pump).

• Hormonal: testosterone for hypoandrogenic men/women; topical estrogens for atrophic vaginitis.

• SSRIs / TCAs off-label to prolong IELT in PE; topical anesthetic sprays/creams.

• Penile prostheses: semi-rigid rod vs. inflatable; vascular bypass in selected arteriosclerotic ED.

Psychosocial & Behavioral Therapies

• Dual-sex (Masters & Johnson)

  • Therapy dyad treats couple; sensate focus hierarchy (non-genital touch → genital → coitus) with intercourse moratorium.

  • Reduces spectatoring & performance anxiety; emphasizes communication.

• Specific techniques

  • Squeeze & stop-start for PE

  • Graduated dilators + pelvic PT for vaginismus/dyspareunia

  • Directed masturbation / vibrators for FOD

  • Extravaginal to intravaginal steps for DE

• Behavior therapy: systematic desensitization, assertiveness training.

• Mindfulness: present-moment sensory focus counters anxiety.

• Group therapy: psychoeducation, peer support; contraindicated in severe depression, psychosis, uncooperative partner.

• Hypnotherapy: trance-based anxiety reduction.

• Analytically-oriented sex therapy: integrates psychodynamic work for deeper conflicts.

Paraphilic Disorders (PDs)

• Definition: \ge 6\,\text{mo} of intense deviant arousal & either (a) acted on with non-consenting person/children or (b) causes marked distress/impairment.

• General features

  • Usually male onset <18\,\text{y}; peaks 15\text{–}25, wanes with age.

  • Often multiple PDs (median 3\text{–}5 per patient).

  • External triggers: anxiety, substance use, stress; fantasies ritualized & stereotyped.

DSM-5 Specific PDs & Highlights

Other Specified PDs

• Telephone/computer scatologia (obscene calls, cybersex compulsions)

• Necrophilia (cadavers)

• Partialism (focus on body part, oralism)

• Zoophilia (animals)

• Coprophilia, urophilia, klismaphilia (feces, urine, enemas)

• Hypoxyphilia / autoerotic asphyxiation (oxygen deprivation)

Etiology & Risk Factors

• Psychosocial: sexualized childhood abuse, early conditioning, modeling, eroticized humiliation, inconsistent discipline.

• Biologic: hormonal anomalies 74\%, neurologic signs 27\%, chromosomal variants 24\% in specialty samples; causal link unclear.

Epidemiology (Table 16-23)

• Outpatient offenders: Pedophilia 45\% (median 5 victims), Exhibitionism 25\% (median 50 acts), Voyeurism 12\%, etc.

• 10\text{–}20\% of children molested; 20\% adult women exposed to exhibitionism/voyeurism.

Prognosis Flags

• Worse: early onset, high frequency, multiple PDs, lack of guilt, comorbid substance use.

• Better: self-referral, single PD, adult attachments, normal IQ, no antisocial traits.

Treatment Modalities

1. External control: incarceration, environmental structuring.

2. Drive reduction

   • Antiandrogens (medroxyprogesterone acetate; cyproterone acetate) ↓ testosterone.

   • SSRIs ↓ intrusive fantasies, compulsivity.

3. Treat comorbidity: antipsychotics, antidepressants, mood stabilizers.

4. Cognitive-behavioral

   • Relapse prevention, trigger management, empathy training, cognitive restructuring, imaginal desensitization.

   • Modified aversive rehearsal (videotaped mannequin enactment → confrontation).

5. Dynamic psychotherapy & sex therapy: address identity, aggression, intimacy deficits.

Sex Addiction / Compulsive Sexual Behavior

• Not in DSM-5; modeled on addiction paradigm.

• Signs (Table 16-24): out-of-control behavior, withdrawal-like mood shifts, escalating needs, repeated failed quit attempts, severe consequences.

• Variants: Don Juanism / satyriasis (male conquest drive), nymphomania (female hypersexuality).

• Comorbidity: Substance use up to 80\%, mood & anxiety disorders.

• Treatment

  • 12-step groups (SA, SLAA, SAA), plus AA/NA if needed.

  • Inpatient when danger, suicidality, or inability to abstain.

  • Pharmacology: SSRIs (intrusive urges), medroxyprogesterone, antiandrogens.

  • Psychotherapies: insight-oriented, CBT trigger work, couples therapy for relational repair.

  • Outcome improves once underlying disorders treated and external structure established.