Psychosexual disorders

Transcription

1 Psychosexual disorders Dr. Roger Ho Assistant Professor and Consultant Psychiatrist Department of Psychological Medicine National University of Singapore

2 I'm not ashamed of being gay, but I'm ashamed to be Singaporean by Wang Su Lin This time next week, I will be marking my second anniversary in starting a new life--and living a new dream -- in Canada. I have been to Canada just once, for all of three weeks. Yet those 20 days were the happiest days of my life. For the first time in a long, long time (the only other time being in Cambridge, England), I experienced true freedom -- the freedom to be myself, without having to suffer the backward glances, the rude remarks and the incessant gossips. But see, here's the thing. I'm gay. I'm not ashamed of it, not by a long shot.

3 If this person comes to see you as a patient, you discover that he is gay during history taking. He faces a lot of stress. What is your view as a doctor? 1. Respect his sexual orientation and it is normal to be gay. 2. Homosexuality is something unnatural and deviant behaviour. 3. There is no scientific evidence to prove homosexuality is inborn. I should help him to change back to heterosexual. 4. I find gay unacceptable and I will not see this patient. 5. Other answer 69% 12% 0% 19% 0%

4 Introduction Sex is an important part of our lives but often much confusion about what is really going on during sex. Easy for sex to get less exciting, repetitious and understanding biological processes can help find ways to avoid this. This is a significant contributing factor to marital problems. The best way to develop a healthy attitude towards sex is to demystify it > sex is very private but something we all do after a certain age so knowledge can be beneficial.

5 Gender identity VS sexual orientation Gender Identity = Social by 2-3yo a sense that I m a boy or I m a girl is firmly set; sense of masculinity & femininity develop based on biology, parental & cultural attitudes Sexual Orientation Object of person s sexual attraction - hetero, homo or bi-.

6 Homosexuality Homosexuality means one is oriented towards choosing people of the same sex as as the partner for sexual satisfaction. The sexual satisfaction includes satisfaction in emotional interest, genitals interest and sexual physiological excitement. False homosexuality refers to people who possess the thought and behaviors of homosexuality, but cannot accept them and always want to change them Kinsey classified homosexualitv into 6 classes. Class 6 is the strongest. They are complete homosexuals, without any interest in heterosexual behavior and experience. Class 1 is the weakest. They only have occasional homosexual behavioral experiences, but they are mainly oriented towards heterosexuality. Those classes in the middle, like Class 3 and 4, are the socalled bi-sexuals. they have the same interests and experiences in heterosexual and homosexual behaviors.

7 Psychiatry and sexology Through psychoanalysis, Freud believed that in childhood little girls masturbate and thus have orgasms by means of clitoral stimulation, or clitoral orgasms. '. He thought that as women grow older and mature. they ought to shift from having orgasms as a result of masturbation to having them as a result of heterosexual intercourse. Thus the vaginal orgasm was considered "mature" and the clitoral orgasm "immature" or "infantile. His theory is not well supported by scientific evidence. Sigmund Freud

8 Master and Johnson: Four Stages of Sexual Response

9 Human sexual response cycle First studied by (William) Masters and (Virginia) Johnson Until then everyone clueless about what went on biologically during intercourse > lots of misinformation Studied 694 people who were able to reach orgasm during sexual intercourse under controlled laboratory conditions Virginia Johnson passed away in 2013.

10 Four Stages of Sexual Response According to Masters and Johnson. there are four stages of sexual response. which they call excitement, plateau, orgasm, and resolution (EPOR). Orgasm: Peak of sexual arousal, release of physical, emotional and psychological build-up. In male, it is usually equivalent to ejaculation. Excitement: muscle tension, some increase in heart rate & blood pressure, areas of the body become engorged. It may result in a sex flush a pink or red rash on the chest and face. Plateau: sexual tension continues to build, last a few seconds to a few minutes Resolution: a return to unaroused state. In males only Refractory period, he is unable to have a 2nd erection or ejaculation, allows his glands to refill.

11 Basic physiological process of sexual responses The two basic physiological processes that occur during these stages are vasocongestion and myotonia. Vasocongestion occurs when great deal of blood flows into the blood vessels in a region, in this case the genitals, as a result of dilation of the blood vessels in the region. Myotonia occurs when muscles contract, not only in the genitals but also throughout the body.

12 Sexual arousal Erotic stimuli - factors in the environment that are sexually arousing. What turns one person on may be totally ineffective in another person (certain underwear, certain music, certain food, certain smells) Often all associated with past sexual encounter(s).

13 Sexual arousal erogenous zones Erotic stimuli possible by all senses touch, vision, hearing, smell, taste Body is most sexually sensitive in certain areas called erogenous zones Some obvious > head of penis, clitoris, mons pubis, vagina, labia, nipples (female) Some less obvious > nipples (male), ear lobes, anus, buttocks ( cheeks ), inner thighs (esp. women) back of knees, soles of feet, eyebrows, lower center of back

14 Sexual response proceptive behaviour Sexual Arousal Flirting, kissing, foreplay (petting), seduction MILD pain, gentle biting Extremely important start of the sexual response cycle

15 Excitement phase in males The excitement phase is the beginning of erotic arousal. The basic physiological process that occurs during excitement is vasocongestion. This produces the obvious arousal response in the male erection. Erection results when the corpora caveroasa and the corpus spongiosum fill (becoming engorged) with blood. Erection may be produced by direct physical stimulation of the genitals. by stimulation of other parts of the body or by erotic thoughts. It occurs very rapidly within a few seconds of the stimulation. although it may take place more slowly as a result of a number of factors including age, in rake of alcohol, and fatigue.

16 Excitement phase in females (1) The glans of clitoris has engorgement and this is very Similar to erection in males. An important response of females in the excitement phase is lubrication of the vagina. This response is very similar to males. Masters and Johnson found that vaginal lubrication results when fluids seep through the semipermeable membranes of the vaginal walls, producing lubrication as a result of vasocongestion in the tissues surrounding the vagina. Lubrication begins 10 to 30 seconds after the onset of arousing stimuli. Female responding can be affected by factors such as age, intake of alcohol. and fatigue.

17 Excitement phase in females (2) During the excitement phase, the upper two- thirds of the vagina expands dramatically in what is often called a "ballooning" response; that is, it becomes more like an inflated balloon. This helps to accommodate the entrance of the penis. As part of the ballooning, the cervix and uterus pull up, creating a "tenting effect" in the vaginal walls and making a larger opening in the cervix. which probably allows sperm to move into the uterus more easily.

18 Excitement phase in females (3) The nipples become erect; this results from contractions of the muscle fibers (myotonia) surrounding the nipple. The breasts themselves swell and enlarge somewhat in the late part of the excitement phase (a vasocongestion response). Thus the nipples may not actually look erect but may appear somewhat flatter against the breast because the, breast has swollen. Many males also have nipple erection during the excitement phase.

19 Plateau phase in males During the plateau phase, vasocongestion reaches its peak. In men, the penis is completely erect, although there may be fluctuations in the firmness of the erection. The glans swells. The testes are pulled up even higher and closer to the body. A few drops of fluid (for some men, quite a few), secreted by the Cowper's gland, appear at the tip of the penis. Although they are not the ejaculate, they may contain active sperm.

20 Plateau phase in females (1) In females, (the most notable change during the plateau phase is formation of the orgasmic platform. This is a tightening of the outer third of the vagina. Thus the size of the vaginal entrance actually becomes smaller, and there may be a noticeable increase in gripping of the penis.

21 Plateau phase in females (2)

22 Orgasm in males In the male. orgasm consists of a series of rhythmic contractions of the pelvic organs at 0.8-second intervals. Actually, male orgasm occurs in two stages. In the preliminary stage. the vas seminal vesicles. and prostate contract, forcing the ejaculate into a bulb at the base of the urethra. Masters and Johnson call the sensation in this stage one of "ejaculatory inevitability" ("coming"); that is, there is a sensation that ejaculation is just about to happen and cannot be stopped. In the second stage, the urethral bulb and the penis itself contract rhythmically, forcing the semen through the urethra and out the opening at the tip of the penis.

23 Orgasm in females The process of orgasm in females is basically similar to that in males. It is a series of rhythmic muscular contractions of the orgasmic platform. The contractions generally occur at about 0.8second intervals; there may be three or four in a mild orgasm or as many as a dozen in a very intense, prolonged orgasm. The uterus also contracts rhythmically. Other muscles. such as those around the anus, may also contract.

24 Other physiological responses in males and females during orgasms In both males and females. there are sharp increases in pulse rate, blood pressure, and breathing rate during orgasm. Muscles contract throughout the body. The face may be contorted in a grimace; the muscles of the arms, legs, thighs, back, and buttocks may contract; and the muscles of the feet and hands may contract in "carpopedal spasms." Generally, in the passion of the moment. one is not really aware of these occurrences, but an aching back or buttocks may serve as a reminder the next day.

25 Variations in female orgasms One can almost never get anyone to give a solid definition of what female orgasm is. Instead, people usually fall back on, "You'll know what it is when you have one." This evasiveness is probably related to several factors, most notably that female orgasm leaves no tangible evidence of its occurrence like ejaculation. Also, women often do not reach orgasm as quickly as man do. The main feeling is a spreading sensation that begins around the clitoris and then spreads outward through the whole pelvis. There may also be sensations of falling or opening up.. The woman may be able to feel the contraction of the muscles around the vaginal entrance. The sensation is more incense than just a warm glow or a pleasant tingllng.

26 Resolution phase Following orgasm is the resolution phase, during which the body returns physiologically to the unaroused state. Orgasm triggers a massive release of muscular tension and of blood from the engorged blood vessels. Resolution then represents a reversal of the processes that build up during the excitement and plateau stages.

27 Resolution phase in males In men, the most obvious occurrence in the resolution phase is detumescence, the loss of erection in the penis. This happens in two stages: the first occurring rapidly but leaving the penis still enlarged (the first loss of erection results from an emptying of the corpora cavernosa) The second occurring more slowly, as a result of the slower emptying of the corpus spongiosum and the glans.

28 Resolution phase in females The first change in women is a reduction in the swelling of the breasts. As a result. the nipples may appear to become erect, since they seem to stand out more as the surrounding flesh moves back toward the unstimulated size. In women who develop a sex flush during arousal, this disappears rapidly following orgasm. In the 5 to 10 seconds after the end of the orgasm, the clitoris returns to its normal position, although it takes longer for it to S shrink to its normal size. The ballooning of the vagina diminishes, and the uterus shrinks.

29 There is refractory period which is refractory to further Stimuli. The duration vary between man: May last up to 24 hours and this refractory Period increases as man grows older.

30 Women do not have refractory period & allows multiple orgasm. That is, if she is stimulated again, she can immediately be aroused and move back to the excitement or plateau phase and have another orgasm.

31 How to get multiple orgasm in females? Multiple orgasm is more likely to result from hand-genital or mouth-genital stimulation than from intercourse, since most men do not have the endurance to continue thrusting for such long periods of time. Masturbation might have 5 to 20 orgasms in a woman. If vibrator is used, women are capable of having 50 orgasms in a row. Some women prefer to have 1 orgasm and do not want more.

32 Variation of sexual response in prostitutes The prostitutes frequently experienced arousal without having orgasms. Thus there were repeated buildups of vasocongestion without discharge of it brought by orgasm. The result was a chronic vasocongestion in the pelvis. A mild version of this occurs in some women who engage in sex but are not able to have orgasms, and it can be quite uncomfortable.

33 You are a GP and working in a polyclinic near Geylang. A commercial sex worker wants to consult you how to use a male condom properly. Which of the following is correct? 1. If the male client ejaculates inside the condom during vaginal intercourse, the penis should be pull out right away. 2. If the male client has no circumcision, leave the foreskin at its original position when putting on a condom. 3. Put the lubricant on the penis before putting on a condom. 4. Squeeze tip when rolling down condom to keep out air bubbles. The bubbles can break the condom. 5. The tip of the condom must closely adhere to the glans penis. 9% 18% 14% 32% 27%

34 How to advise patient to use a condom properly You need to use a new condom every time you have sexual intercourse; from the moment the penis first comes into contact with the vagina or anus, until there is no contact. Never use the same condom twice. Only put on a condom once there is a partial or full erection. Open the condom packet at one corner being careful not to tear the condom with your fingernails, your teeth, or through being too rough. Make sure the packet and condom appear to be in good condition, and check that the expiry date has not passed.

35 Place the rolled condom over the tip of the hard penis, whilst pinching the tip of the condom enough to leave a half inch space for semen to collect. Never unroll the condom before putting it onto the penis. If the penis is not circumcised, pull back the foreskin before rolling on the condom. Roll the condom all the way down to the base of the penis, and smooth out any air bubbles. (Air bubbles can cause a condom to break.)

36 A man likes to perform cunnilingus on his female partners. He worries about getting STD. What is your advice? 1. Cunnilingus is safe and he does not need to worry about STD. 2. Cunnilingus is safe as long as he does not have a wound in his mouth. 3. Cunnilingus is safe as long as he does not insert his tongue into the vagina. 4. He should stop the practice of cunnilingus as it is not hygienic. 5. There is a method to protect him from getting STD during cunnilingus. 5% 14% 0% 52% 29%

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38 Other models of human sexual responses Cognitive-Physiological Models: Criticism of Master and Johnson s model: focus too much on peripheral issues and ignore perception, cognitive evaluation and learning theory. The cognitive model explains individual variations.

39 Other model (2): Hormonal and neural control Erection is produced by a spinal reflex. Stimulation produces a neural signal which is transmitted to an "erection center" in the sacral. or lowest, part of the spinal cord. This center then sends out message via the parasympathetic division of the autonomic nervous system to the muscles around the walls of the arteries then expand, permitting a large volume of blood to go in. Ejaculation centre is located higher in spinal cord and Involves sympathetic nervous system

40 Neuroanatomical areas for sexual response It appears that the most important influences come from a set of structures called the limbic system. The limbic system forms border between the central part of the brain and the outer part of [the cerebral cortex); it includes the amygdala,,the hippocampus, the clngulate gyrus, the fornix. and the septum. The thalamus, the hypothalamus, the pituitary, and the reticular formation are not properly part of the limbic system, but they areclosely connected to it.

41 Testosterone and sexual desire Testosterone has welldocumented effects on libido, or sexual desire, in humans. It has also been demonstrated that levels of testosterone ore correlated with sexual behavior in boys around the time of puberty. Sexual desire is rapidly lost if a man is given an antiandrogen drug.

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43 Controversial topics

44 A 20-year-old university student comes to see you. He needs to masturbate 3 times a day and spends 5 hours per day watching pornography. He cannot reduce his urge for sex. He tries to engage in sexual activities by meeting women through chat line. He has good past health and no past psychiatric illness. He is not manic during the interview. He cannot concentrate in his studies. What is your opinion? 1. He suffers from sexual addiction. 2. He suffers from ICD-10 excessive sexual drive. 3. He is considered to be normal. 4. He has moral problems. 5. Other answers. 52% 22% 22% 4% 0%

45 Does woman a Grafenberg (G) -spot? 1. Yes, I believe woman has an anatomical structure called G- spot. 2. No, there is no such anatomical structure. 3. Other answers. 65% 26% 9% 1 2 3

46 G - spot Grafenberg spot (GRAY-lenberg) or. Gospet: A hypothesized small region on the front wall of the vagina, emptying into the urethra and responsible for female ejaculation. Stroking It produces an urge to urinate. but if the stroking continues for a few seconds more, it begins to produce sexual pleasure.

47 Non therapeutic circumcision (e.g. cultural practice) removing foreskin from penis Recommendation from British Medical Association: In the past, circumcision of boys has been considered to be either medically or socially beneficial or at least neutral. The general perception has been that no significant harm was caused to the child and therefore with appropriate consent it could be carried out. The medical benefits previously claimed, however, have not been convincingly proven, and it is now widely accepted, including by the BMA, that this surgical procedure has medical and psychological risks. It is essential that doctors perform male circumcision only where this is demonstrably in the best interests of the child. The responsibility to demonstrate that non-therapeutic circumcision is in a particular child s best interests falls to his parents. The BMA considers that the evidence concerning health benefit from non-therapeutic circumcision is insufficient for this alone to be a justification for doing it.

48 Variations of sexual response cycle

49 Sexual dysfunction in relationship to cycle Orgasmic Disorders -F/M Orgasmic Disorder -Premature Ejaculation Sexual Arousal Disorders -Male ED Sexual Desire Disorders Hypoactive SDD Sexual Aversion Sexual Pain Disorders -Dyspareunia -Vaginismus

50 DSM-IV Sexual Dysfunctions In Men Hypoactive Sexual Desire Disorder Sexual Aversion Disorder 1 Male Erectile Disorder 2 Male Orgasmic Disorder 3 Premature Ejaculation 4 Dyspareunia In Women Hypoactive Sexual Desire Disorder Sexual Aversion Disorder 1 Female Sexual Arousal Disorder 2 Female Orgasmic Disorder 3 Dyspareunia 4 Vaginismus

51 Rates of sexual dysfunction (from Nolen- Hoeksema, 2001, p.527) Lack of Interest: 13-17% (males), 27-32% (females) Unable to achieve orgasm: 7-9% (males), 22-28%(females) Climax too early: 28-32% (males), NA (female) Erectile difficulties: 11-18% (males) Lubrication difficulties: 18-27% (females).

52 Aetiology of sexual disorders Physical Causes: chronic medical illnesses Medications: antidepressants: erectile dysfunction, antipsychotics: erectile dysfunction, antihypertensives: erectile dysfunctions. Alcohol: low dose increase desire, high doses & chronic use à erectile dysfunction à Morbid jealousy Recreational drugs: Marijuana or Cannabis decrease sexual desire; cocaine, amphetamines and benzodiazepines (due to disinhibition) increase sexual desires. Psychological causes: 1) Performance anxiety 2) Thoughts distract a person from focusing on erotic experiences 3) Failure to communicate with a partner 4) Failure to engage in sexually stimulating behaviour due to lack of sexual knowledge, earlier traumatic experience, being punished for masturbation.

53 Simple treatment for sexual dysfunctions Bibliotherapy refers simply to the use of a self-help book to treat a disorder. Cognitive-Behavioural Therapy Cognitive restructuring is an important technique in a cognitive approach to sex therapy).

54 Sex therapy The therapy itself consists of homework assignments, counselling, and education. Modern therapies have incorporated cognitive restructuring as well (as a more direct approach to changing misconceptions about sex). The homework assignments are largely behavioural (and resemble graduated exposure techniques in phobia treatment), and the counselling is used to appraise the couples reactions to these behavioural tasks. In cognitive restructuring, the therapist essentially helps the client restructure his or her thought patterns, helping them to become more positive.

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56 Sexual arousal disorder Sexual arousal disorder refers to a lack of response to sexual stimulation. In women, it is defined partly by the woman's own subjective sense that she does not feel aroused and partly by difficulties with vaginal lubrication. Difficulties with lubrication are common; they were reported by 19 percent of the women. These problems become particularly frequent among women during and after menopause: as estrogen levels decline, vaginal lubrication decreases.

57 Disorders of Sexual Desire Hypoactive sexual desire (HSD) People with HSD typically avoid situations that will evoke sexual feelings. If, despite their best efforts they find themselves in an arousing situation, they experience a rapid "turn-off" so that they feel nothing. The turn-off may be so intense that they report negative, unpleasant feelings; they may even report sexual anesthesia, that is, no feeling at all, even though they may respond to the point of having an orgasm. Women usually report HSD in their early thirties, whereas men usually do in their mid to their late forties. Women with HSD were also more likely than men with HSD to be dissatisfied with the quality of!heir relationship, and particularly with the expression of affection.

58 Discrepancy in sexual desire That is, if one partner wants sex considerably less frequently than the other partner does, there is a conflict. Based on the survey conducted by the Singapore unit of the Menarini Group, close to 80 per cent of women from the city-state aged 18 to 45 would like to have more sex, compared to 69 per cent of their counterparts in Asia-Pacific. What worries Singapore men? Six in 10 are extremely concerned about not being able to satisfy their partners, compared to only 38 per cent for the region at large. Almost half the local men surveyed fear that they are unable to bring their partners to a climax, and almost three in 10 worry about premature ejaculation (PE).

59 Treatment of sexual desire or sexual arousal disorder in a couple Sensate focus therapy Sensate focus exercises are based on the notion at touching and being touched are important forms of sexual expression and that touching is also an important form of communication. Non-genital sensate focus: This is the first stage in the process and this emphasis physical contact without touching any sexual areas (I.e. genitalia, breasts). Kissing and caressing is all that s allowed. Couples are encouraged to engage in massage and to communicate about what they enjoy. This stage is very useful for couples with a pessimistic outlook (because of repeated failure) and for those that have difficulty discussing their problems. The banning of intercourse ensures that these homework assignments are done without any feeling of pressure or anxiety about what will happen (because both parties know that full sex is off limits).

60 Sensate focus therapy (2) Genital-sensate focus: this stage is the natural extension of the previous one with the no-go areas now being removed. Intercourse is still forbidden but as time moves on couples are encouraged to engage in masturbation (with each other). At this stage specific techniques can be introduced, for example, for premature ejaculation there is the stop-start technique devised by Semans (1956) in which the partner masturbates the man until he is very highly aroused and then stops and allows his erection to subside before beginning again. This process is repeated a number of times (3-6) before the man is allowed to ejaculate. This helps develop control of the ejaculatory reflex.

61 Sensate focus (3) Vaginal containment: The final stage involves penetration without movement. The female (usually in the female-superior position) inserts her partner s penis into her vagina and they both lie still and focus on any pleasant sensations. This can be a key step in getting used to the sensation in premature ejaculation, and for vaginismus (in which penetration is a crucial part of the problem).

62 Sexual aversion disorders in males (1) Erectile Disorder Erectile disorder is the inability to have an erection or maintain one. In primary erectile disorder, the man has never been able to have an erection that is satisfactory for intercourse. In secondary erectile disorder, the man has difficulty getting or maintaining an erection but has " had erections sufficient for intercourse at other times.

63 Erectile dysfunction - Causes Perhaps 50 percent or more of cases of erectile disorder may be due to organic factors or to a combination of organic factors and other factors. Diseases associated with the heart and the circulatory system. Diabetes is an important factor. Spinal cord injury Performance anxiety

64 Treatment of erectile dysfunction (1) Viagra (sildenafil citrate) is dispensed as a pill and ingested orally. The mechanism of erection of the penis involves release of nitric oxide (NO) in the corpus cavernosum during sexual stimulation. NO then activates the enzyme guanylate cyclase, whi.ch results in increased levels of cyclic guanosine monophosphate (cgmp), producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood. Viagra enhances the effect of nitric oxide (NO) by inhibiting phosphodiesterase type 5 (PDE5), which is responsible for degradation of cgmp in the corpus cavernosum. The increase in cgmp resulting in smooth muscle relaxation and inflow of blood to the corpus cavernosum.

65 Side effects of sildenafil Side effects: Headache Flushing, Dyspepsia, Nasal congestion Impaired vision (photophobia and blurred vision)

66 Treatment of erectile dysfunction (2) Uprima is the first clinically tested sublingual medication to enhance erections by activating chemicals found in the brain. Uprima tablets are dissolved under the tongue which stimulate dopamine receptors in the hypothalamus and mid brain regions. Subsequently, once sexual stimulation as occurred an excitatory signal is transmitted via the spinal I cord to stimulate parasympathetic activity in the pelvic region.

67 Tadalafil (the weekend pill) Tadalafil (Cialis) is a PDE5 inhibitor. The third drug for treatment in erectile dysfunction. Longer half-life in Tadalafil (17.50 hours) as compared to Viagra ( hours) and Levitra ( hours) Common side effects due to vasodilation: headache, indigestion, back pain, muscle aches, flushing, and stuffy or runny nose. Severe side effects: visual loss and hearing loss.

68 Treatment of erectile dysfunction (3) Suction Devices Suction devices are another treatment for erectile disorders Essentially, they pump the penis up. With some devices, the mouth can produce enough suction; with others, a small hand pump is used. Once a reasonably firm erection is present. the tube is removed and a rubber ring is placed around the base of the penis to maintain the penis's engorgement with blood.

69 Sexual aversion disorders in males (2) Premature Ejaculation Premature ejaculation occurs when a man has orgasm and ejaculates too soon. (< 1 min following vaginal penetration) In extreme cases, ejaculation may take place so soon after erection that it occurs before intercourse can even begin.

70 Premature ejaculation - causes Early ejaculation is more often caused by psychological rather than physical factors. A local infection such as prostatitis may be the cause, as may degeneration in the related parts of the nervous system, which may occur in neural disorders such as multiple sclerosis.

71 Treatment of premature ejaculation The Stop-Start Technique The stop-start technique is used in the treatment of premature ejaculation The woman uses her hand to stimulate the man to erection. Then she stops the stimulation. Gradually he loses his erection. She resumes stimulation, gets another erection, she stops, and so on. Another version of this method is the squeeze technique, in which the woman adds at squeeze around the coronal ridge, which also stops orgasm. Antidepressant: selective serotonin reuptake inhibitors can be used

72 Male orgasmic disorder Delayed ejaculation The man is unable to have an orgasm, even though he has a solid erection and has had more than adequate stimulation. It maybe associated with a variety of medical or surgical conditions such as antidepressant treatment multiple sclerosis, spinal cord injury, and prostate surgery

73 Female orgasmic disorder Female orgasmic disorder is the inability to have orgasm. Primary orgasmic disorder refers to cases in which the woman has never in her life experienced an orgasm. Secondary orgasmic disorder refers to cases in which the woman had orgasms at some time in her life but no longer does so. Situational orgasmic disorder, in which the woman has orgasms in some situations but not others

74 Female sexual aversion disorders (1) Painful Intercourse Painful intercourse, or dyspareunia, refers simply to pain experienced during Intercourse. Endometriosis In women, pain may be felt in the vagina, around the vaginal entrance and clitoris, or deep in the pelvis. In men, the pain is felt in the penis or testes.

75 Causes of painful intercourse in females Disorders of the vaginal entrance: Irritated remnants of the hymen; painful scars, perhaps from an episiotomy or sexual assault; or infection of the Bartholin glands. Disorders of the vagina Vaginal infections; allergic reactions to spermicidal creams or the latex in condoms or diaphragms; a thinning of the vaginal walls, which occurs naturally with age; or scarring of the roof of the vagina, which occurs after hysterectomy. Pelvic disorders Pelvic infection such as pelvic inflammatory disease, endometriosis, tumors, cysts, or a tearing of the ligaments supporting the uterus.

76 Female sexual aversion disorders (2) Vaginismus Vaginismus a spastic contraction of the outer third of the vagina; in some cases it is so severe that the entrance to the vagina is closed. and the woman cannot have intercourse

77 Treatment of vaginismus Dilator Set Sizes: Unit Front Diameter Back Diameter Length 1 - Dilator 3/4" [19mm] 7/8" [22mm] 3-1/2" [90mm] 2 - Dilator 15/16" [24mm] 1-1/16" [27mm ] 4-5/16" [110mm ] 3 - Dilator 1-1/8" [30mm] 1-1/4" [32mm] 5-1/2" [140mm] 4 - Dilator 1-3/8" [35mm] 1-1/2" [38mm] 6-3/8" [163mm] 5 - Handle

78 Critiques of DSM IV diagnosis Women s experience of sexuality especially may not match the Masters & Johnson model. Access to sexual pleasure is strongly affected by cultural norms and by oppression. DSM-IV classification and M&J model ignores the relationship context in which sex occurs. Focus is on fixing the genitals not attending to relational and cultural barriers to sexual pleasure. This focus encourages the development of drugs to address these problems, rather than social, relational, or personal change. Furthermore, this focus does not reflect sexual problems as many people experience them.

79 Alternatives to DSM IV diagnoses World Association for Sexology s Declaration of Sexual Rights The Working Group on a New View of Women's Sexual Problems: A New Classification Sexual Problems = discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience May arise in any or several of the following areas: 1. Sexual problems due to socio-cultural, political, or economic factors 2. Sexual problems relating to partner or relationship 3. Sexual problems due to psychological factors 4. Sexual problems due to medical factors

80 Sexual response in intellectual disability Persons with IQs below 70 are generally classified as having learning disability. There is a great range in the capacities of retarded individuals, from some who require institutionalization and constant care, to those who can stay in the community. Four issues are especially important when considering the sexuality of mentally retarded persons: their opportunity for sexual expression, the need for sex education, the importance of contraception, and the possibility of sexual abuse.

81 Variations in sexual preferences and responses

82 A 40-year-old man wants to consult you. About 3 months ago, he visited a prostitute in the Red Light district of Amsterdam. According to him, the prostitute used a strapon. He was quite guarded to provide further details. He wants to know whether it was possible to have contracted HIV. Your answer is: 1. Yes, it was possible to have contracted HIV. HIV test is indicated. 2. No, it was very unlikely to have contracted HIV. Reassure the patient. 3. I do not know what a strapon is and I cannot provide any advice. 41% 27% 32% 1 2 3

83 You are an AED resident. The nurse informs you that a woman came to the AED with her dog and covered in a blanket. She was guarded and asked for help as her dog s penis stuck into her vagina for hours. Your management plan is: 1. Consult the gynaecologist on 40% call and aim at exploration of the woman s genitalia under general anaesthesia. 2. Put a lot of KY-jelly to help the dog s penis to come out of her 24% 24% vagina. 3. Report this woman to the police for animal abuse and she has committed an offence in Singapore. 8% 4. Sedate the dog. 4% 5. Send this patient to IMH because she must be psychotic to have sex with a dog

84 Paraphilia = abnormal sexual preferences Fetishism = the preferred or only means of achieving sexual excitement are inanimate objects or parts of the human body that do not have direct sexual associations. Being in adolescence More common in men (most are heterosexual) Treatment: CBT Prognosis: worse in single man without sexual partner.

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87 Two types of fetishism In a media fetish, the material out of which an object is made is the source of arousal. An example would be a leather fetish, in which any leather item is arousing to the person. In a form fetish, it is the object and its shape that are important. An example would be a shoe fetish, in which shoes are highly arousing

88 Transvestism Transvestism ("trans"="cross"; "vest"="dressing") refers to dressing as a member of the other gender. Cross-dressing may be done by a variety of people for a variety of reasons. As has been noted, male transsexuals may go through a stage of crossdressing, in the process of becoming women.

89 Sadism and Masochism A sadist is a person who derives sexual satisfaction, from inflicting pain on another person. A masochist is a person who is sexually aroused by experiencing pain. Sadomasochism is often accompanied by elaborate rituals and gadgetry, such as tight black leather. clothing, pins and needles, ropes, whips, and hot wax.

90 Voyeurism (to see) There are two types of voyeur: In scoptophilia, sexual pleasure is derived from observing sexual acts and the genitals; in voyeurism, technically. the sexual pleasure comes from viewing nudes, often while the voyeur is masturbating.

91 Exhibitionism The complement to voyeurism is exhibitionism. ("flashing ). in which the person derives sexual pleasure from exposing his genitals to others in situations where this is clearly inappropriate.

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93 Causes of sexual offending Driving factors Paraphilias (eg pedophilia, sadism) Preferential arousal Exclusive arousal (some drugs/ alcohol may enhance) Hypersexuality/high sex drive (some drugs increase drive) Disinhibiting factors Impaired judgment Alcohol, drugs Brain injury Mental disorders Developmental delay Cognitive distortions Distorted values re: sexual behaviours due to one s own sexual abuse Distorted values re: victims (Eg many sexual assaults on women by antisocial physically abusive men who see women as objects)

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95 Childhood sexual abuse Sex Crimes are common Sexual Assault ~1/6 American women are victims of attempted/completed sexual assault 3% of men In studies conducted mostly in developed countries, 5 10% of men report being sexually abused as children (Kinsey institute website based on WHO 2004 data) Child Sexual Abuse 1/1000 per year incidence with prevalence of 12-27% of girls and 8-16% of boys

96 Paedophilia 6 mo of sexual urges towards prepubescent child (usu 13yo) Acted on urges or urges caused significant distress, impairment or interpersonal problems Person is at least 16yo, victim at least 5 yrs younger Overall, <3% of population 95% are heterosexual 50% have consumed alcohol at time ofoffence >90% are men Many have also committed exhibitionism, voyeurism & rape Often feel more accepted by kids, have low self-esteem or body image problems Subtypes: sexually attracted to,, both; incest only; exclusive/nonexclusive type

97 In 2010, the South Korea government proposed chemical castration for male sex offenders. Do you agree the Singapore government also adopts the same treatment for sex offenders? 1. Yes, I agree 2. No, I do not agree. 3. I have no comment. 41% 27% 32% 1 2 3

98 Treatment 1. External Control Can include indeterminate sentencing Release conditions Including sex offender registration, community notification, and castration 2. Reduce Sex Drive Partial Sex Drive Reduction SSRI s Cyproterone (Androcur) Medroxyprogesterone (Provera) Ablation of Testosterone Leuprolide (Lupron) Goserelin (Zoladex) Inhibit peripheral testosterone (adjunct) Finasteride

99 Testoesterone antagonist General workup Premedication LH, FSH, Serum f-testosterone, LFTs, Hgb, CBC, glucose, renal function, EKG, Bone density, weight, blood pressure Endocrinology consultation On meds Monthly testosterone x 4 then q6mo BUN, Creat, LH, Prolactin q 6mo Bone density yearly if on Leuprolide or Goserelin uottawa rd E.K. Koranyi Review Course in Psychiatry Page 188 Cyproterone (Androcur) Testosterone antagonist mg/d po or mg/week IM Contraindicated in liver disease & thromboembolic disease 15-20% get gynecomastia (excess of estradiol/estrogen vs testosterone) Weight gain & decreased body hair often occur Risk of fatigue or depression

100 Recividism Overall 5 year recidivism = 13.4% 12.7% for child molesters 18.9% for rapists Incest offenders the lowest at 4-10% Prenky et al.2 gave a 25 year rate of 39% for rapists 53% for extrafamilial child molesters

101 A 19-year-old man was referred by SAF for pre-enlistment assessment. He dresses like a female and speaks in a female tone. He has been saving money to go to Thailand for sex reassignment surgery. He expresses difficulty to serve NS as he feels excited when seeing men in the bathroom. What do you recommend? 1. He is going to serve NS as per normal and remain on the highest PES status. 2. He is advised to be downgraded. 3. He is advised to stay out at night and avoid sharing a common bathroom with other NSmen. 4. He should receive weekly psychotherapy to change his idea to change gender as this is a psychiatric illness. 5. He should be totally exempted from NS. 23% 58% 4% 4% 12%

102 Lady boys: the intermediate sex / Cultural bound phenomenon The term kathoey or katoey generally refers to a male to female transgender person. It is most often rendered as ladyboy in English conversation with Thais and this latter expression has become popular across SE Asia except in the Philippines where the term bakla is often used. (wikipedia) They have not undergone sex reassignment surgery. They are known as third sex or intersex which is more acceptable in the Thai culture than transexual. They are asking for constitutional change for having third gender in Thailand. Kathoeys usually work in traditionally feminine occupations: bars or even prostitutes.

103 Gender identity disorder of childhood For girls: The child shows persistent and intense distress about being a girl, and has a stated desire to be a boy. Either of the following must be present: Persistent marked aversion to feminine clothing and insistence on wearing stereotypical masculine clothing, e.g. boys underwear and other accessories Persistent rejection of female anatomical structures, as evidenced an assertion that she wants to have a penis; ii) refuse to urinate in a sitting position; iii) assertion that she does not want to grow breasts or have menses. The girl has not yet reached puberty. Duration of symptoms: at least 6 months. For boys, the symptoms are very similar to girls. The pre-pubertal child shows persistent and intense distress about being a boy, and has a desire to be a girl. The child prefers female activities and clothing and rejects male anatomical structure. Duration of symptoms is 6 months.