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CLINICAL PRACTICE GUIDELINES for MANAGEMENT of SEXUAL DYSFUNCTIONS Dr

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CLINICAL PRACTICE GUIDELINES for MANAGEMENT of SEXUAL DYSFUNCTIONS Dr CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF SEXUAL DYSFUNCTIONS Dr. Ajit Avasthi1, Dr.T. S. S. Rao2, Dr. Sandeep Grover3, Dr. Parthasarathy Biswas4, Dr. Suresh Kumar1 INTRODUCTION Sexual dysfunction is a major healthcare issue and therefore it deserves attention, consideration, proper investigation, and appropriate treatment. The purpose of these guidelines is to present a framework for the evaluation, treatment, and follow-up of the patient/couple, who presents with sexual dysfunction. These guidelines also discuss the cause and, the available treatments to recognize and rectify disorders of sexual functioning. These guidelines address the complexity involved in diagnosing the various aspects of the disorder and offer an organized system of care for the couple.The guidelines are evidence based, to a large extent. We hope that these guidelines would help in facilitating proper management and avoiding unnecessary expense and inconvenience. Sexual problems are highly prevalent in men and women, yet frequently under-recognized and under­ diagnosed in clinical practice. Even among clinicians who acknowledge the relevance of addressing sexual issues in their patients, there is a general lack of understanding of the optimal approach for sexual problem identification and evaluation (Hatzichristou, 2004). It is important to understand that sexual functioning is a complex bio-psycho-social process, coordinated by the neurological, vascular and endocrine systems. While evaluating sexual functioning of an individual it is important to incorporate family, societal and religious beliefs, health status, personal exper-ience, ethnicity and socio- demographic conditions, and psychological status of the person/couple. In addition, sexual activity incorporates interpersonal relationships, each partner bringing unique attitudes, needs and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction. Problems of sexual dysfunction may be lifelong or acquired, general or situational. Adequate attention to these aspects during the history taking will educate the often-uninformed patient regarding the complex nature of sexuality, and prepare him for understanding treatment and outcome realities.The rational selection of therapy by patients is only possible following appropriate education, including information about sexuality and all treatment options for sexual/erectile dysfunction. Although not always possible on the first visit, every effort should be made to involve the patient's sexual partner early in the therapeutic process. The treating physician and collaborating specialists should possess broad knowledge about human sexuality. The essential concepts underlying the management of sexual problems are adoption of a patient- centered framework for evaluation and treatment, application of the principles of evidence-based medicine in diagnostic and treatment planning and adoption of common management approaches for sexual dysfunction in both men and women. CLASSIFICATION OF SEXUAL DISORDERS An adult's sexuality has seven components: gender identity, orientation, intention (what one wants to do with the partner's body and have done with one's body during sexual behaviour), desire, arousal, orgasm and emotional satisfaction (Levine, 1989). The first three components constitute our sexual identity and the next three comprise our sexual function. The seventh component of emotional satisfaction is based on personal reflections on the first six components. Accordingly, sexual disorders are often classified into three groups: Sexual dysfunctions (problem of phases of sexual functioning), Department of Psychiatry, PGIMER, Chandigarh 1'-4-5 Department of Psychiatry, J.S.S Medical College, Mysore * (144) paraphilias (problem of intention) and gender identity disorders (problem of identity). Problems of sexual orientation, i.e. homosexuality are not included in the nosological systems. Sexual dysfunctions Masters and Johnson (1966) first characterized the sexual response cycle as consisting of four successive phases: excitement, plateau, orgasmic, and resolution (EPOR model). Later on Kaplan (1974) found that many of her female patients professed that they have no desire to be sexually aroused, even by their partners. Following this she proposed that the sexual cycle consist of four successive phases, viz., desire, excitement (arousal), orgasm and resolution (DEOR model), which later on became an accepted model. Later on this model formed the basis of classification of sexual disorders. Accordingly, "Sexual dysfunction was referred to a problem during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity". According to DSM-IVTR, the category of sexual dysfunctions is further sub-divided into 4 categories: (1) primary, (2) general medical condition-related, (3) substance-induced, and (4) not otherwise specified. The advantage of the above classification is that all sexual function disorders are grouped together, notwithstanding their etiology. Each of the 4 DSM-IVTR categories has disorders in all 3 sexual phases. Further DSM- IV required that the disturbance in sexual desire or in the psychophysiological changes that characterize the sexual response cycle must cause marked distress and/or interpersonal difficulty before it can be termed a disorder. DSM-IV also describes subtypes of various sexual dysfunctions to indicate the onset, context and etiological factor associated with the disorder (Table-1). Further as per DSM-IV, if multiple sexual dysfunctions are present, the appropriate subtype of each may be noted. According to ICD-10 sexual dysfunction refers to a person's inability to "participate in a sexual relationship as he or she would wish". Compared to DSM-IVTR, ICD-10 doesn't try to describe various sexual dysfunctions according to various phases of sexual cycle. ICD-10 describes various categories of sexual dysfunctions under the broad heading of "Sexual dysfunction, not caused by organic disorder or diseases". The various categories included are Lack or loss of sexual desire, Sexual aversion and lack of sexual enjoyment, Failure of genital response, Orgasmic dysfunction, Premature ejaculation , Nonorganic vaginismus, Nonorganic dyspareunia, Excessive sexual drive, Other sexual dysfunction, not caused by organic disorder or disease and Unspecified sexual dysfunction, not caused by organic disorder or disease. Table-2 gives comparison of sexual dysfunctions as conceptualized in the versions of DSM-IVTR and ICD -10. Various authors have criticized ICD-10 classification for not being specific about the phases of the sexual response cycle at places. For example, ICD-10 describes a disorder as a "failure of genital response." According to various authors this description is rather confusing. Without consulting the criteria set, it is not clear if the genital response in question is the response during the phase of sexual arousal (genital vasocongestion and, therefore, erection and lubrication) or during the orgasmic phase (involuntary contractions of all kinds of muscle groups). But it is important to remember that the accepted diagnostic categories for sexual dysfunction described in ICD-10 and DSM-IVTR do not reflect the reality of sexual dysfunctions in the clinical setting. When these classifications are used it must be remembered that sexual dysfunctions are not all or nothing phenomena but occur on a continuum both in terms of frequency and severity. With our current knowledge, any cut off is inevitably arbitrary. It is also rarely possible to identify cases with a purely organic or purely psychogenic aetiology. Indeed, with growing knowledgeof psychoneuropharmacology and endocrinology, the distinction between organic and psychogenic is increasingly becoming blurred. Another important aspect to remember is that comorbidity of sexual dysfunctions is common. For example, nearly half of men with low sexual desire have another sexual dysfunction, and 20% of men with erectile dysfunction have low sexual desire. (145) Table-1: Subtypes of sexual dysfunctions according to DSM-IV Subtypes Onset Lifelong: present since the onset Acquired: develops after a period of sexual functioning of normal functioning Context Generalized : not limited to certain Situational: limited to certain types of stimulation, situation or types of stimulation, situation or partner partner etiology Due to psychological factors: Due to combined factors: when when psychological factors have a psychological factors and general major role in the onset, severity, medical condition or substance exacerbation or maintenance of the use is also judged to be sexual dysfunction contributory Table-2: Comparison of diagnostic categories of ICD-10 & DSM-IVTR of sexual disorders Disorders according ICD-10 DSM-IVTR to sexual cycle Sexual desire • Lack or loss of sexual desire • Diminished sexual desire disorders • Sexual aversion • Sexual aversion • Excessive sexual drive • Excessive sexual desire Sexual arousal • Failure of genital response • Genital arousal disorders disorders • Sexual excitement disorders Orgasm disorders • Orgasmic dysfunction • Orgasmic disorder • Lack of sexual enjoyment • Anhedonic orgasm • Premature ejaculation • Premature orgasm • Ejaculation disorders Sexual pain disorders • Nonorganic dyspareunia • Dyspareunia • Nonorganic Vaginismus • Vaginismus • Paraphilias • Sexual dysfunction due to general • Gender identity disorders medical condition • Other
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