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Sexual & Gender Identity Disorders Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Question: What is different between men and women in their sexual response cycles? Sexual & Gender Identity A.A.EngorgementEngorgement of genitals during arousal Disorders B.B.NippleNipple erection C.C.IncreaseIncrease in respiration during arousal Jack Krasuski, MD D.D.RefractoryRefractory period after orgasm American Physician Institute for Advanced Professional Studies [email protected] 2 Question: Which of the following Question: The most prevalent male statements regarding paraphilias is sexual disorder is which of the true? following? A.A. Paraphilias are found equally among men and A.A. Premature ejaculation women B.B. Erectile dysfunction B.B. Paraphilias usually do not cause distress C.C. The paraphilia of fetishism involves watching C.C. Orgasmic disorder naked people D.D. Hypoactive sexual desire disorder D.D. Paraphilias can benefit from treatment 3 4 Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 1 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Question: A 22 year old woman presents to clinic with the complaint that she doesn’t want to have sex with her Question: When the outer third of the vagina boyfriend because it seems “disgusting.” She has had three previous relationships end because of her refusal to spasms during sexual intercourse in a manner have sex. She does, however, wish to have close that prevents intercourse or causes pain, this is companionship and is disappointed by her breakups most likely a manifestation of which disorder? precipitated by her feelings toward sex. Her most likely diagnosis is? A.A. Anorgasmia B.B. Dyspareunia A.A. Hypoactive Sexual Desire Disorder B.B. Dyspareunia C.C. Sexual Disorder NOS C.C. Sexual Aversion Disorder D.D. Somatization Disorder D.D. Female Orgasmic Disorder E.E. Vaginismus E.E. Female Sexual Arousal Disorder 5 6 Question: Male Erectile Disorder is Question: Cognitive distortions associated with disturbance in which present in pedophiles are likely to stage of the sexual response cycle? include versions of all of the following except? A.A. Desire A.A. Sex is a sign of love and mutuality B.B. Arousal B.B. I am guiding the child to mature relations C.C. Orgasmic C.C. Children are sexual beings too D.D. Resolution D.D. Sexual impulses are controllable E.E. Recurrence E.E. Adults have a right to have sexual relations with whom they choose 7 8 Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 2 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Question: A 22 year old biological male presents to clinic, stating, “I’m transgender and need to be cleared Lecture Agenda by psychiatry to begin receiving hormone therapy.” He endorses having feelings that he’s ‘a woman trapped in a man’s body’ for as long as he can remember. Despite The sexual response cycle this, he does not wish to undergo sex reassignment Sexual Dysfunctions surgery. His most likely diagnosis is? Paraphilias A.A. Gender Identity Disorder Gender Identity Disorders B.B. Gender Identity Disorder NOS C.C. Transvestic Fetishism, With Gender Dysphoria D.D. Sexual Dysfunction NOS E.E. Sexual Orientation Disorder 9 10 Sexual Response Cycle Desire Stage Linear Stage Theory Cycle Theory Sexual drive/libido Desire Stage Emotional closeness, Motivation/desire to have sex Arousal Stage sexual arousal, and Involves sexual fantasies sexual desire form a Orgasmic Stage Lasts for minutes to hours to days reinforcing cycle Resolution Stage More consistent with female sexual response 11 12 Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 3 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Arousal Stage Orgasmic Stage Psychological and physiological Peaking of sexual pleasure ––EjaculationEjaculation stimulation Rhythmic contraction of perineal muscles Penile erection / vaginal lubrication & Involuntary pelvic thrusting engorgement Involuntary contractions of anal sphincters Nipple erection in both sexes Increase in heart rate, blood pressure, and Blood pressure and pulse increase acutely respiration in both sexes Lasts 55--1515 seconds Stage of sexual activity Obligatory refractory period in men Lasts minutes to hours Women can have multiple orgasms 13 14 Resolution Stage Sexual Dysfunctions DSM-IV Sexual Desire Disorders Sexual Pain Disorders Disgorgement of blood from genitaliagenitalia—— Hypoactive Sexual Desire Dyspareunia detumescence Disorder Vaginismus Sexual Aversion Disorder Sexual Dysfunction Due Sense of wellwell--beingbeing and relaxation Sexual Arousal Disorders to GMC Refractory period in men for minutes to Female Sexual Arousal SubstanceSubstance--InducedInduced hours Disorder Sexual Dysfunction Male Erectile Disorder No refractory period in women Sexual Dysfunction NOS Orgasmic Disorders Female Orgasmic Disorder Male Orgasmic Disorder 15 16 Premature Ejaculation Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 4 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Sexual Dysfunctions: Subtypes Diagnosis: Clarification Onset Biological Factors (GMC / Substance) Lifelong Type Vs. Acquired Type Psychological Factors Context Generalized Type Vs. Situational Type Etiologic Factors Due to Psychological Factors Sexual Sexual Sexual Dysfunction - Dysfunction - Dysfunction - Due to Combined Factors: Psychological plus Due To Due To Due to GMC GMC or substance Psychological Combined Or Substance Factors Only Factors Induced 17 18 Sexual Dysfunction: Sexual Dysfunction: Biological Psychosexual Factors Factors Psychiatric disorders GMC Neuro, Endocrine, Vascular Stress Medications Relationship conflicts Antihypertensives, Chemotherapeutic agents, CNS Abuse / Trauma (current or past) medications Physical Substances Emotional Alcohol and other drugs Sexual Biological Correlates Age and gender 19 20 Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 5 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Hypoactive Sexual Desire Disorder Hypoactive Sexual Desire Disorder Sexual Desire Disorder Features DSMDSM--IVIV Diagnosis Common in marriage: 35% women; 16% men Deficiency or absence of sexual fantasies and desire HSDD: 75% of women treated for any sexual disorder for sexual activity Biological factors: low testosterone Marked distress or interpersonal difficulty Psychological factors: stress, depression, anxiety Relational factors: conflict, perceived level of partner’s Not better accounted for by another Axis 1 disorder, libido and sexual satisfaction Substance or General Medical Condition Differential Types Secondary to drugs / meds, a GMC Lifelong Vs. Acquired Depressive and anxiety disorders Generalized Vs. Situational Sexual Aversion Disorder, Erectile Dysfunction 21 Due to Psychological or Combined Factors 22 Hypoactive Sexual Desire Disorder: Sexual Aversion Disorder Treatment Sexual Desire Disorder Assess for any GMC / Substance Factor DSMDSM--IVIV Diagnosis Therapy Persistent & recurrent aversion to and avoidance of genital contact with a sexual partner Couples Therapy / Sensate Training Sexual opportunity creates anxiety & fear Psychoeducation Marked distress or interpersonal difficulty Medications Not better accounted for by another Axis 1 disorder, Testosterone: for men and women SubstanceSubstance--InducedInduced or General Medical Condition Bupropion Types Erectile Dysfunction Meds: for men and women Lifelong Vs. Acquired, Generalized Vs. Situational, Due to Psychological OR Combined Factors 23 24 Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 6 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Sexual Aversion Disorder Sexual Aversion Disorder: Treatment Features Psychological Factors: childhood or current Assess for any GMC / Substance Factor sexual abuse, stress, fatigue, specific fears Relational Factors: poor relationship, poor sexual Therapy technique of partner CBT Differential Diagnosis Treat any comorbid PTSD, depression Hypoactive Sexual Desire Disorder (CBT, IPT, Psychodynamic Therapy) Vaginismus, Dyspareunia Sensate Training Sexual Pain Due GMC Psychoeducation Undiagnosed STD Vulvar vestibulitis: chronic pain syndrome Couples Therapy 25 Vulvodynia: Chronic discomfort: burning, itching 26 Female Sexual Arousal Disorder Female Sexual Arousal Disorder Sexual Arousal Disorder Etiologic Factors DSMDSM--IVIV--TRTR Diagnosis Physical Factors Persistent or recurrent inability to attain or maintain Vascular, neurologic, Diabetes Mellitus an adequate lubrication / swelling Response Stress and fatigue Marked distress or interpersonal difficulty Psychosocial Factors Not better accounted for by another Axis 1 disorder, Childhood abuse, fatigue, stress, poor relationship SubstanceSubstance--InducedInduced or General Medical Condition Treatment Types Assess for any GMC / Substance Factor Lifelong Vs. Acquired, Generalized Vs. Situational, Couples Therapy / Individual Therapy Due to Psychological OR Combined Factors Erectile dysfunction meds for women? 27 28 Copyright 2009 Krasuski www.BeatTheBoards.com 877-225- 8384www.BeatTheBoards.com 877-225- 8384 7 Sexual & Gender Identity DisordersSexual 2/9/2010 Disorders Male Erectile Disorder Erectile Dysfunction: GMC Factors Sexual Arousal Disorder DSMDSM--IVIV--TRTR
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