Sexual Disorders

Gender Identity

Gender dysphoria (transsexuality) is characterized by subjective feelings of gender discomfort, in which patients feel that they were born the wrong sex. Distinguish it from transvestism, which is a paraphilia of dressing up as the other gender for sexual gratification.

Many patients with gender identity disorder ultimately undergo sex-reassignment procedures. To improve the prognosis of these procedures, patients can live their life as the desired gender for the months leading to treatment.

Hormone-suppression therapy can be offered by Tanner stage 2 of development to delay puberty and give patients time to decide how to proceed. The medication has many side effects, so any decision about it should be made with support from family and/or friends, if possible.

The most appropriate response is to provide nonjudgmental support, offer education about his options going forward (such as hormonal therapy), and encourage him to develop potentially supportive relationships (eg, parents, friends, mentors).

Exploring sexuality in adolescence is developmentally appropriate. However, gender dysphoria is diagnosed when there is an intense and persistent desire to be another gender, which causes significant distress. Gender dysphoria in early childhood does not always persist; when experienced through adolescence and especially into puberty, gender dysphoria is more likely to be enduring and should be addressed; discussions should not be delayed.

Paraphilia

Are characterized by preoccupation with unusual sexual urges and activities., Except when illegal, they are assumed not to be pathological. Paraphilias are pathological if they are severe enough to interfere with social or occupational functioning.

Pedophilia

Pedophilia is sexual gratification from fantasies/acts with children age 13 or younger.

Frotteurism

Sexual gratification from rubbing against non-consenting people.,

Voyeurism

Voyeurism is sexual gratification from watching unsuspecting people nude (e.g. in shower).

Exhibitionism

Exhibitionism is sexual gratification from exposing oneself in public.

Sadism

Sadism is sexual excitement derived from hurting or humiliating someone.

Masochism

Sexual excitement derived from being humiliated or hurt.,

Fetishism

Fetishism is sexual excitement elicited from an inanimate object (e.g. shoes).

Transvestism

Transvestism is usually a heterosexual man deriving pleasure from dressing up as a woman.

Necrophilia

Necrophilia is sexual pleasure from having sex with dead people.

Psychotherapy is the standard treatment for pathological paraphilias.

Antiandrogens can be used in men to curtail sexual desire.

Age related sexual changes

The desire for sex does not usually decrease as people age, though the body may be physiologically less responsive.

Men have a decreased intensity of orgasm, with a longer refractory period.

Women experience vaginal dryness and thinning after menopause. Changes in the vaginal mucosa and corresponding bacterial flora may predispose to recurrent UTIs. Estrogen replacement therapy may be of benefit for both vaginal dryness and recurrent UTIs in this scenario.

Sexual Disorders

Sexual disorders include disorders of desire, arousal, orgasm, and pain. As of DSM-5, sexual disorders are male and female-specific.

• Disorders of desire: Hypoactive sexual desire disorder and female sexual interest/arousal disorder

• Disorders of arousal: Erectile dysfunction (impotence)

• Disorders of orgasm: Female orgasmic disorder, delayed ejaculation disorder, and premature ejaculation

• Sexual pain disorders: Genito-pelvic pain/penetration disorder

As of DSM-5, all sexual disorders except those caused by medication or substance abuse require >6 months of duration.

Genitopelvic pain

Genito-pelvic pain/penetration disorder is a new diagnosis in DSM-5, and is a combination of dyspareunia (painful intercourse) and vaginismus (involuntary muscle contraction of vagina during penetration).

Impotence

Impotence (erectile dysfunction) is the inability to attain an erection. When considering an etiology of impotence, one should consider:

• Organic causes

• Psychiatric causes

• Substance-induced causes

Step 2 questions on erectile dysfunction often contain multiple risk factors (e.g. a diabetic with depression experiences impotence after a night of drinking), so one must be astute and read all the given information carefully. With all etiologies, look for a temporal relationship to the dysfunction.

Organic (non-psychogenic) causes of erectile dysfunction include diabetes/vascular disease, neurologic disorders, and endocrine dysfunction. Suspect organic causes when patients do not get morning erections. Other clues for organic causes include:

• Non-episodic, consistent erectile dysfunction

• Other symptoms of organic disease (e.g. angina, claudication)

Psychological causes of erectile dysfunction include stress and anxiety (including performance anxiety), depression, and history of sexual trauma. Suspect psychological causes when patients have inconsistent dysfunction (e.g. not with other partners, not while masturbating). Other clues for psychological causes include:

• No clear precipitant, except for psychosocial issues

• Young patients (<50 years old)

Substance-induced causes of erectile dysfunction are directly caused by alcohol, illicit drugs, or prescription medications. Suspect this form of dysfunction in unprecedented, episodic dysfunction. Some medications to look out for include:

• Alcohol

• Marijuana

• Antihypertensives

• SSRIs

• Antipsychotics

Phosphodiesterase-5 inhibitors are commonly used for erectile dysfunction.

SSRIs are a classically tested treatment for premature ejaculation. SNRIs may be used as well.

Other sexual disorders can be treated with psychotherapy, pharmacotherapy, and/or mechanical devices.