Sexuality

Overview

Definition of terms

Homosexuality

Homosexuality is a normal variant of sexual orientation (removed from the DSM). It is a label taken on by the patients, who will lead a normal life, but just happen to be attracted to the same gender. Most patients report attraction to the same sex since their early teen years. Their sexual development is however normal. Homosexuality is an IDENTITY, not a diagnosis. Therefore, for medical purposes, use MSM, WSW etc.

• Why are there higher rates of MDD and suicide in homosexual patients?
  • Growing up in a culture that stigmatizes their sexuality. They don’t get much acceptance, may be abandoned etc.
• What is NOT homosexuality?
  • Teenage or adolescent experimentation
  • Visual comparison of genitals
  • Handholding, kissing, etc. (especially among women or men in Arab countries. Take culture into consideration)

Masturbation

Masturbation is a normal, universal incidence. It’s the self-stimulation of genitals. Males tend to masturbate more than females (probably due to higher sex drive). Frequency peaks during adolescent years (experimentation/identity establishment). Not considered a disorder unless it interferes with activities of daily life.

• Phallic stage
  • 1-2 year old infants engage in self-stimulation of genitals (exploration)
  • No sexual component
  • Normal

Paraphilias

Sexual arousal to objects, situations, and individuals, that is outside normative stimulation or what is considered to be acceptable (Take the patient’s culture into consideration). Must cause distress to the patient, affect the patient’s level of functioning or break the law in the jurisdiction to be considered a disorder.

Paraphilias

• Definition according to the AJP
  • Recurrent, intense, sexually arousing fantasies, sexual urges, or behaviours generally involving:
    • Non-human objects (Fetishism)
    • The suffering of humiliation of oneself or one’s partner (masochism, sadism)
    • Children (paedophilia, ephebophilia)
    • Non-consenting persons (exhibitionism, frotteurism, voyeurism)
• Management
  • Psychotherapy (if disordered)

Gender Dysphoria

Trying to destigmatize (might be normal). A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration. The individual has to be uncomfortable with their assigned sex (different from gender non-conformity). Adults may eventually get hormones/surgery to transition. Children can be given meds to halt puberty so that when they become adults they can make the decision. Sex change is irreversible.

• Manifestation of gender dysphoria in children ***Remember to use common sense.
  • Preponderance to play with toys associated with other sex
  • Toilet habits associated with opposite sex
  • Friends primarily of opposite sex etc.
• When to make a diagnosis of gender dysphoria
  • When the patient outwardly expresses disappointment with their current sex OR desire to be the opposite sex
  • Do not diagnose using behaviour alone (particularly in children)
• Management
  • Psychotherapy
  • Sexual reassignment (Sex-change)

Disorders of Desire

May not be distressing to the patient. Psychotherapy may not be desired/necessary.

Disorders of desire

Disorders of Arousal

Female sexual arousal disorder

Failure to achieve adequate lubrication during sex. Often d/t anxiety, nervousness, fear etc.

• Differentials
  • Medications that cause dryness (antihistamines, anticholinergics): Most commonly diphenhydramine for allergies and ipratropium for COPD (anything that dries out the mouth will dry the vagina)
• Management
  • Alternative medications (if meds are the cause)
  • Psychotherapy
  • Synthetic lubricants

(Male) Impotence

Failure to achieve OR maintain erection. Seen commonly in older gents. The man may be psychologically aroused, but he may not be able to maintain an erection. R/o physiological causes.

• How can distinguish between physiological causes of impotence a psychological causes (Psychogenic ED)
  • Ask the patient if he has an erection when he wakes up in the morning (nocturnal penile tumescence)
  • If yes, r/o physiological cause
• Differentials
  • Diabetes Mellitus
  • Peripheral Vascular disease
  • Psychogenic ED (Seen in gents with anxiety disorders, repressed homosexuals etc.)
• Treatment
  • Psychotherapy
  • Sildenafil, Tadalafil (can also be given as a placebo to psychogenic ED, as long as there are no contraindications -Pt on Nitrates etc.)

Disorders of Orgasm

Premature ejaculation syndrome

Ejaculation earlier than desired. Very very common. Commonly seen in teenage boys, young men, and college-age gents (”Soon as I put the tip in it’s over Doc…”)

• Treatment
  • “Squeeze technique” – wards off orgasm most of the time
  • SSRIs (Sertraline)

Anorgasmia

Recurrent or persistent inability to achieve orgasm

• Differentials
  • SSRI use – Zoloft/Lexapro (switch to bupropion – Wellbutrin; Don’t use bupropion in pts with seizure disorders)
• Treatment
  • Psychotherapy (difficult to treat if not related to meds
  • Switch to bupropion if on SSRI

Disorders of Pain During Sex

Dyspareunia

Pain associated with sex NOT associated with lack of lubrication or organic medical cause

• Differentials
  • Female sexual arousal disorder (does not lubricate)
  • Endometriosis (pain comes from endometriomas)
  • Hypoplasia of vaginal introitus (vagina not big enough)
  • Lichen sclerosis (white plaques, treated with steroids)
  • Candidiasis (fungal infection, treated easily)
• Treatment
  • Psychotherapy

Vaginismus

Involuntary contraction of the outer 1/3 of the vagina which results in pain during penetration

• Treatment
  • Dilators (Gradually increase size) or Fingers