Sexuality

Definitions

• Sex/Sexual identity
  • A person’s biological sex, based on their chromosomes and external and internal features
    • XY – Males (except for androgen insensitivity syndrome – develop as female in utero, doesn’t get menarche)
    • XXY – Males (Klinefelter’s syndrome)
    • XX – Female
    • X0 – Female (Turner’s syndrome)
• Gender identity
  • The sex of a person’s psychlogical identity based on cultural sex roles.
• Cis gender
  • Gender identity corresponds to biological sex
• Trans gender
  • Gender identity does not correspond to biological sex
• Sexual orientation
  • Defined according to gender identity , not sex.
  • Based on the sex towards which a person is sexually attracted to. Considered to be fluid, but generally a person assumes a label of identity
• Heterosexual
  • Attracted predominantly to the opposite gender
• Bisexual
  • Attracted to both genders relatively equally
• Homosexual (Gay/Lesbian)
  • Attracted predominantly to the same gender
• Transvestic Fetishism
  • Sexual arousal from cross-dressing or playing the role of the opposite sex
• Drag Queen
  • Cross-dressing for entertainment

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/adolescent experimentation
  • Visual comparison of genitals
  • Handholding, kissing, etc. (especially among women or men in Arab countries. Take culture into consideration)

Masturbation

Totally normal, universal incidence. It’s the self-stimulation of genitals. Males tend to masturbate more than females (probably d/t 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
  • 1-2yo 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.

• 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)

Paraphilias involving non-human objects

• Fetishism
  • Sexual arousal from objects associated with the human body
    • Garments
    • Leather items
    • Rubber and rubber items
    • Footwear
• Transvestic fetishism
  • Sexual arousal from cross-dressing or playing the role of the opposite sex

Paraphilias involving suffering/humiliation (SNM)

• Sadism
  • Sexual arousal from inflicting pain
  • Can be a big problem (sociopathic) if the other person does not consent to it/high danger level
• Masochism
  • Sexual arousal from receiving pain
  • Disorder depends on the danger level

Paraphilias involving children

• Pedophilia
  • Sexual arousal from intimate contact with OR watching of prepubescent children
  • Illegal in virtually every country
• Ephebophilia
  • Sexual arousal from intimate contact with or watching of pubescent teens under the age of 18
  • (not particularly disordered from a biological standpoint. But STILL ILLEGAL)

Paraphilias involving non-consenting persons

• Exhibitionism
  • Sexual pleasure from exposure to unsuspecting strangers
• Frotteurism
  • Sexual pleasure from rubbing up against an unsuspecting stranger
• Voyeurism
  • Sexual pleasure from spying on sexual or private acts of unsuspecting strangers

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.

Hypoactive sexual desire

Low sexual desire (only a disorder if it is distressing to the patient)

Sexual aversion (disorder)

Absent sexual interest (only a disorder if it is distressing to a patient). A lot of these patients have survived rape (afraid of sex, which interferes with their ability to form relationships)

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