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** COR CHRISTI ** Subject: Psychiatry Topic: Abnormal Sexuality and Sexual Dysfunctions Transcribers: Mating Cats =^.^= ABNORMAL SEXUALITY AND SEXUAL DYSFUNCTIONS The syndromes are correlated with the sexual physiological response, which is divided into four phases. The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or in the objective performance. - can occur alone or in combination - lifelong or acquired - generalized or situational - due to psychological factors - due to physiological factors - or due to combined factors - due to a general medical condition or substance abuse - due to substance abuse -psychiatric syndromes: - depressive disorders, - anxiety disorders, - personality disorders, - schizophrenia - psychological -relational problems -increasing fear of failure -self consciousness about their sexual performance -stress of any kind -can be symptomatic of biological (biogenic) problems coded in Axis III -can be symptomatic of interpersonal (psychogenic) conflicts -can be combination of these factors -ignorance of sexual function and physiology Sexual dysfunction Disturbance in the sexual response cycle or pain with sexual intercourse Sexual desire disorders Sexual arousal disorders Orgasm disorders Sexual pain disorders Caused by a general medical condition Substance induced Not otherwise specified Diagnostic criteria for a specific sexual phase disorder A. Dysfunction

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C. The sexual dysfunction is - not better accounted for by another Axis I disorder, or - not due exclusively to the direct physiological effects of a substance - not due to a general medical condition Sexual Desire Disorder Hypoactive sexual desire disorder - persistent or recurrent deficient sexual fantasies and desire for sexual activity. Sexual aversion disorder - persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital contact with a sexual partner Presence of desire depends on several factors: - biological drive, - adequate self-esteem, - the ability to accept oneself as a sexual person, - previous good experiences with sex, - the availability of an appropriate partner, - good relationship in non-sexual areas with a partner Causative factors: - patients with desire problems often use inhibition of desire defensively - to protect against unconscious fears about sex Sigmund Freud conceptualized low sexual desire as the result of inhibition during the phallic psychosexual phase of development and of unresolved oedipal conflicts. Some men, fixated at the phallic state of development, are fearful of the vagina and believe that they will be castrated if they approach it. He called this concept Vagina dentate Vagina dentate because men unconsciously believe that the vagina has teeth, they avoid contact with the female genitalia. Equally, women may suffer from unresolved developmental conflicts that inhibit desire. -Lack of desire can also result from chronic stress, anxiety, or depression. -abstinence from sex for a prolonged period sometimes results in suppression of sexual impulses -expression of hostility towards a partner -sign of deteriorating relationship, marital discord, Sexual Arousal Disorder

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the diagnosis takes into account the o focus o intensity o duration of the sexual activity. female sexual arousal disorder: - persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubricationswelling response of sexual excitement psychological factors: anxiety, guilt, fear Physiological studies of sexual dysfunctions indicate that a hormonal pattern may contribute to responsiveness. - women are particularly desirous of sex before the onset of the menses. - other women report feeling the greatest sexual excitement immediately after the menses or at the time of ovulation - alterations in testosterone, estrogen, prolactin, and thyroxin levels have been implicated in female sexual arousal disorder Medications with antihistaminic or anticholinergic properties - cause a decrease in vaginal lubrication.

Some evidence indicate that these women are less aware of the physiological arousal of their bodies and experience less warmth or less sensation in the genitalia

male erectile disorder -persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection -organic or psychological or a combination of both -in young and middle aged men, it is usually psychological -Freud ascribed one type of impotence to an inability to reconcile feelings of affection toward a woman with feelings of desire for her. Men with such conflicting feelings can function only with women whom they see as degraded ( Madonna = Putana complex ) -punitive superego -an inability to trust -feelings of inadequacy or a sense of being undesirable as a partner -fear, anger, anxiety, or moral prohibition -in an ongoing relationship, it may reflect difficulties between partners -episodes of impotence are reinforcing, with the man becoming increasingly anxious before each sexual encounter Orgasm Disorders Female/ Male orgasmic disorder

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persistent or recurrent delay, or absence of, orgasm following a normal sexual excitement phase

female orgasmic disorder - fear of impregnation - fear of rejection by a sex partner - fear of damage to the vagina - hostility toward men - feelings of guilt about sexual impulses Some women equate orgasm with loss of control or with aggressive, destructive, or violent impulses; their fear of these impulses may be expressed through inhibition of excitement or orgasm. - cultural expectations and social restrictions on women - belief that sexual pleasure is not a natural entitlement for socalled decent women. male orgasmic disorder (inhibited orgasm or retarded ejaculation) - lifelong male orgasmic disorder indicates severe psychopathology o man may come from rigid puritanical background o perceive sex as sinful o perceive genitalia as dirty o conscious or unconscious incest wishes and guilt may be aggravated by attention-deficit disorder a mans distractibility prevents sufficient arousal for climax to occur

In an ongoing relationship, acquired male orgasmic disorder frequently reflects interpersonal difficulties. - may be a mans way of coping with real or fantasized changes in the relationship, such as plans of pregnancy about which the man is ambivalent - loss of sexual attraction to the partner - demands for greater commitment - unexpressed hostility towards the woman - more common with obsessive compulsive disorder premature ejaculation - persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. researchers have divided these men into two groups: 1. those who are physiologically predisposed to climax quickly because of shorter nerve latency time 2. those with a psychogenic or behaviorally conditioned cause -

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associated with anxiety regarding the sex act unconscious fears about the vagina negative cultural conditioning

Men whose early sexual contacts occurred largely with prostitutes who demanded that the sex act proceed quickly or whose sexual contacts took place in situation in which discovery would be embarrassing might have been conditioned to achieve orgasm rapidly. Psychodynamics found in premature ejaculation and impotence are similar. Sexual dysfunctions not associated with the sexual response cycle. Sexual Pain Disorders Vaginismus involuntary muscle constriction of the outer third of the vagina Dyspareunia - pain occurring in either men or women before, during, or after intercourse. psychodynamic factors: - chronic pelvic pain is a common complaint in women with history of rape or childhood sexual abuse - tension and anxiety about sex act that cause women to involuntarily contract their vaginal muscles - aggravated if partner proceeds with intercourse regardless of a womans state of readiness uncommon but can also occur in man - usually associated with organic condition such as o herpes o prostatitis o peyronies disease sclerotic plaques on the penis that cause penile curvature vaginismus involuntary muscle constriction of the outer third of the vagina - woman may consciously wish coitus but unconsciously wish to keep the penis from entering her body - pain or anticipation of pain at the first coital experience - sexual trauma - psychosexual conflicts -may perceive penis as a weapon -woman may feel emotionally abused by her partner and protest in this nonverbal fashion sexual dysfunction not otherwise specified:

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erotic sensation despite normal physiological response to sexual stimulation (orgasmic anhedonia) organic causes such as sacral and cephalic lesions that interfere with afferent pathways from the genitalia to the cortex, must be ruled out extreme guilt about experiencing sexual pleasure dissociative response that isolates the affective component of the orgasmic experience from consciousness female analogue of premature ejaculation a case of multiple spontaneous orgasms without sexual stimulation was seen in a woman- cause was an epileptogenic focus in the temporal lobe spontaneous orgasm associated with yawning in women taking antidepressants

o postcoital headache
o PARAPHILIAS pathognomonic element of a paraphilia: -special fantasy with it unconscious or conscious components - sexual arousal and orgasm reinforces the fantasy or impulse - abnormal expressions of sexuality - the person has acted out on sexual impulses and fantasies which resulted to marked distress or interpersonal difficulty - caused marked impairment in social, occupation or other important areas of functioning Major functions of human sexual behavior: - to assist in bonding - to create mutual pleasure in cooperation with a partner - to express and enhance love between two persons - to procreate paraphilias divergent behaviors in that those acts involve: aggression, victimization, and extreme one-sidedness behaviors exclude or harm others and disrupt the potential for bonding between persons vascular, muscle-contraction (tension) psychogenic

genital pain occurring during masturbation

Diagnosis and clinical features Presence of a pathognomonic fantasy

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- an intense urge to act out the fantasy or its behavioral elaboration - the fantasy contains unusual sexual material that is relatively fixed - arousal and orgasm depend on the mental elaboration or the behavioral playing out of the fantasy - sexual activity is ritualized or stereotyped and makes use of degraded, reduced, or dehumanized objects. Etiology: Psychosocial factors: In the classic psychoanalytic model, persons with a paraphilia have failed to complete the normal developmental process toward heterosexual adjustment, but the model has been modified by new psychoanalytic approaches. However, bizarre the manifestations, the resulting behavior provides an outlet for the sexual and aggressive drives that would otherwise have been channeled into proper sexual behavior. What distinguishes one paraphilia from another is the method chosen by a person to cope with the anxiety caused by the threat of castration by the father and separation from the mother. Failure to resolve the oedipal crisis by identifying with the fatheraggressor (for boys) or mother aggressor (for girls) results either in improper identification with opposite sex parent or in an improper choice of object for libido cathexis. transsexualism and transvestic fetishism are disorders because each involves identification with the opposite-sex parent instead of the same-sex parent: man dressing in womens clothes identify with his mother exhibitionism castration and voyeourism attempts to calm anxiety about

*exhibitionism - refers to a desire or compulsion to expose parts of one's body in a public or semi-public circumstance, in crowds or groups of friends or acquaintances, or to strangers. * voyeourism - is the sexual interest in or practice of spying on people engaged in intimate behaviors, such as undressing, sexual activity, or other activity usually considered to be of a private nature. fetishism attempt to avoid anxiety by displacing libidinal impulses to inappropriate objects: shoe fetish unconsciously denies that women have lost their penises through castration by attaching libido to a phallic object, the shoe, which symbolizes the female penis pedophilia and sexual sadism need to dominate and control their victims to compensate for feelings of powerlessness during the oedipal crisis. some theorists believe that choosing a child as a love object is a narcissistic act

sexual masochism overcome their fear of injury and their sense of powerlessness by showing that they are impervious to harm. - another theory proposes that the masochist directs the aggression inherent in all paraphilias toward herself or himself Other theories attribute the development of a paraphilia to early experiences that condition or socialize children into committing a paraphiliac act. The first shared experience can be important in that regard. -molestation as a child can predispose a person to accept continued abuse as an adult or, conversely, to become an abuser of others. -early experiences of abuse that is not specifically sexual, such as spanking, enemas, or verbal humiliation, can be sexualized by a child and can form the basis for a parahilia. Such experiences can result in the development of an eroticized child. -onset of paraphiliac acts can result from the persons modeling his behavior on the behavior of others who have carried out paraphiliac acts, mimicking sexual behavior depicted in the media, or recalling emotionally laden events from the past, such as his own molestation. The fantasizing of paraphiliac interests begins at an early age and because personal fantasies and thoughts are not shared with other who could block or discourage them, these continue uninhibited until late in life. Only then does the person realize that such paraphiliac interests and urges are inconsistent with societal norms. Unfortunately, by that time the repetitive use of such fantasies has become ingrained, and the sexual thoughts and behaviors have become associated with, or conditioned to, paraphiliac fantasies. Biological factors: Studies on such patients have identified the ff: - those with positive organic findings included o 74% with abnormal hormone levels o 27% with hard or soft neurological signs o 24% with chromosomal abnormalities o 9% with seizures o 9% with dyslexia o 4% with abnormal electroencephalograms o 4% with major mental disorders o 4% with mental handicaps are these causally related to paraphiliac interests? incidental? Gender Identity Disorder - a persistent and intense distress about his or her assigned sex - a desire to be, or an insistence that he or she is, of the other sex

A strong and persistent preference for the status and role of the opposite sex. The affective component of GID is commonly referred to as gender dysphoria (discontent with ones biological sex, the desire to possess the body of the opposite sex, and the wish to be regarded as a member of the opposite sex) extreme forms transsexualism -commonly involve attempts to pass as a member of the opposite sex in society and to obtain hormonal and surgical treatment to stimulate the phenotype of the opposite biological sex. GID not otherwise specified: - Intersex conditions - Turners syndrome - Klinefelters syndrome - Androgenital syndrome - Pseudohermaphroditism - Androgen insensitivity syndrome - Cross-dressing Etiology Biological factors: resting state is initially female fetus develops, a male is produced only if androgen is introduced thus, maleness or masculinity depend on perinatal androgens. However, gender identity result more from postnatal live events than from prenatal hormonal organization. Testosterone affects brain neurons that contribute to the masculinization of the brain in such areas as the hypothalamus. Whether testosterone contributes to so called masculine or feminine behavioral patterns in gender identity disorders remains a controversial issue. Recent findings point to a difference in the brain of male to female transsexuals. In a postmortem sample of 6, the red nucleus corresponded in size to that of typical females rather than of typical males; independent of whether the male transsexual was heterosexual or homosexual. Psychosocial factors: Children develop a gender identity consonant with their sex of rearing ( also known as assigned sex). The formation of gender identity is influenced by the interaction of childrens temperament and parents qualities and attitudes. There are culturally acceptable gender roles: Boys are not expected to be effeminate Girls are not expected to be tomboys There are boys games and girls toys Roles are learned although some investigators believe that some boys are temperamentally delicate and sensitive and that some girls are

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aggressive and energized- traits that are stereotypically known in todays culture as feminine and masculine respectively SF believed that GID problems resulted from conflicts experienced by children within the oedipal triangle. These conflicts are fuelled by both real family events and childrens fantasies. Whatever interferes with a childs loving the opposite-sex parent and identifying the same sex parent interferes with normal gender identity. Quality of the mother-child relationship in the first years of life is paramount in establishing gender identity. During this period, mother normally facilitate their childrens awareness of, and pride in, their gender. Children are valued as little boys and girls, but devaluing, hostile mothering can result in gender problems. At the same time, separation-individuation process in unfolding. When gender problems become associated with separation-individuation problems the result can be the use of sexuality to remain in relationships characterized by shifts between a desperate infantile closeness and a hostile devaluing distance. Some children are given the message that they would be more valued if they adopted the gender identity of the opposite sex. Rejected or abused children may act on such a belief. Gender Identity problems can also be triggered by a mothers death, extended absence, or depression, to which a young boy many react by totally identifying with her that is, becoming a mother to replace her. The fathers role is also important in the early years, and his presence normally helps the separation-individuation process. Without a father, mother and child may remain overly close. For a girl, the father is normally the prototype of future love objects, for a boy, the father is a model for male identification. Intersex conditions: Gross anatomical or physiological aspects of the opposite sex. 1. Turners Syndrome One sex chromosome is missing XOMinimal development of the gonads, sexual tissues remain in female resting state: - Webbed neck, short stature, broad chest, absence of sexual maturation

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Klinefelters Syndrome (XXY) Male habitus but Y chromosome effect is weakened by presence of the second x chromosome:

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Testes are small and infertile, penis may also be small. During adolescence may develop gynecomastia

Congenital Virilizing Adrenal Hyperplasia (adrenogenital syndrome) - Caused by excess of androgens acting on the fetus - Mild clitoral enlargement - External genitalia that look like a normal scrotal sac, testes, and a penis, but hidden behind these external genitals are a vagina and a uterus.

Psychiatric disorders related to Reproduction Postpartum Depression Postpartum Psychosis Pseudocyesis treatment Sex-reassignment surgery Hormonal treatment Treatment of intersex conditions Conditions present at birth, true medical emergencies, addressed as early as possible A decision must be made about the assigned sex and how the child should be reared Panel of pediatric, urological, and psychiatric experts determines the sex of rearing on the basis of clinical examination, urological studies, buccal smears, chromosomal analyses, and assessment of the parental wishes Education of parents and presentation of range of options open to them Surgery before age 3 Treatment of cross -dressing Combined psychotherapy and pharmacotherapy Stress factors that precipitate behavior are identified Help patients cope with the stressors appropriately, and eliminate them

Medications: antianxiety and antidepressants Treatment: Before 1970 individual psychotherapy Sexual inadequacy arise from early developmental conflicts Sexual disorder is treated as part of a pervasive emotional disturbance Focus on exploration of unconscious conflicts, motivation, fantasy, and various interpersonal conflicts

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Addition of behavioral techniques is necessary to cure the sexual problem Dual-sex Therapy Concept of marital unit or dyad as the object of therapy Male and female therapy team discusses and works through problems with the couple Short term and behaviorally oriented Specific exercises are prescribed Specific techniques and exercises - Graduated dilators - Squeeze technique - Stop-start technique - Masturbation - vibrators Hypnotherapy Focus specifically on the anxiety-producing symptom, the particular sexual dysfunction Focus is on symptom removal and attitude alteration Patients are taught relaxation techniques to use on themselves before sexual relations Behavior Therapy Sexual dysfunction is learned maladaptive behavior, which causes patient to be fearful of sexual interaction Set up hierarchy of anxiety-provoking situations from the least to the most threatening Master anxiety through systematic disensitization Initial mastery of anxiety may need: Medication Hypnosis Special training in deep muscle relaxation Assertiveness training Variation participation of partner in the disensitization program Group Therapy May be an adjunct to other forms of therapy Therapy group provides a strong support system provides a useful forum in which to

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counteract sexual myths, correct misconceptions, provide accurate information Analytically Oriented Sex Therapy Sex therapy integrated with psychodynamic and psychoanalytically oriented psychotherapy Addition of psychodynamic conceptualizations to behavioral techniques allow treatment of patients with other psychopathology Pharmacotherapy Oral Sildenafil (Viagra) Injectable and transurethral Alprostadil Cream, gel Anxiolytics Antidepressants Hormone therapy, androgens Surgical treatment Male prosthesis Mechanical treatment Vacuum pump