Disorders of sexual functions

Dr Kowsar Ahmed
Professor and Head
Department of Psychiatry
PMC
 Sexual Dysfunction
Sexual dysfunction is difficulty experienced by an individual or
partners during any stage of normal sexual activity, including
physical pleasure, desire, preference, arousal, or orgasm.

The World Health Organization defines sexual dysfunction as a

―person's inability to participate in a sexual relationship as
they would wish‖.

Sexual dysfunction refers to persistent physical issues,

psychological problems, or both that prevent someone from
engaging in sexual activities. It can affect any phase of the
sexual response cycle, from arousal to orgasm, and can involve
various potential causes.
 Sexual Dysfunctions

• Sexual factors were considered to be important in

psychodynamic theories of causation and, perhaps related to this
historical view, more attention was paid to the patient’s sexual
history, attitudes, and behaviour than is now usual.

• Disorders of sexual function, preference, and gender identity

were often attributed to mental illness and therefore in the
domain of psychiatry.

• Gender identity refers to one’s sense of being male or female.

When this sense of identity is at variance with an individual’s
anatomical sex, that person is said to have a gender dysphoria
(formerly gender identity disorder).
 Sexual Dysfunctions

• In men, sexual dysfunction refers to repeated impairment of

normal sexual performance, and less often to impairment of
sexual interest and pleasure.

• In women it more often refers to a repeated unsatisfactory quality

to the experience, or to impaired desire for it.

• Sexual activity can affect a person’s social health as well as their

mental, emotional, and physical well-being. Sexual dysfunction
can lower a person’s quality of life and self-esteem, and harm
their relationships with sexual partners.
 Classification of sexual and gender identity disorders (DSM-V)
1. Sexual dysfunctions:-Sexual desire/ arousal disorders:-
• a. Female sexual interest/ arousal disorder.
• b. Male hypoactive sexual desire disorder.
• c. Erectile disorder.

2. Orgasmic disorder:-
• a. Female orgasmic disorder.
• b. Delayed ejaculation.
• c. Premature ejaculation.
• d. Genitopelvic pain/ penetration disorder.
• e. Substance/ medication- induced sexual dysfunction.

3. Paraphilic disorders:-
• a. Anomalous sexual preference's
• i. Exhibitionistic disorder.
• ii. Voyeuristic disorder..
• iii. Frotteuristic disorder.
• iv. Sexual masochism disorder.
• v. Sexual sadism disorder.

• b. Anomalous target preferences

• i. Paedophilic disorder.
• ii. Fetishistic disorder.
• iii. Transvestic disorder

4. Gender dysphoria:-
• a. In children
• b. In adolescents and adults
• Problems of sexual dysfunction are also classified into those
that affect:
• ● Sexual desire and sexual enjoyment.
• ● The genital response (erectile impotence in men, and lack of
arousal in women).
• ● Orgasm (premature or delayed ejaculation in men, and
orgasmic dysfunction in women).
• Paraphilic disorders are recurrent, intense, sexually arousing fantasies, urges, or
behaviors that are distressing or disabling and that involve inanimate objects,
children or nonconsenting adults, or suffering or humiliation of the person or a
partner, with the potential to cause harm.

• The most common paraphilias are pedophilia (sexual focus on children),

exhibitionism (exposure of genitals to strangers), voyeurism (observing private
activities of unaware victims), and frotteurism (touching or rubbing against a
nonconsenting person).

• Orgasmic dysfunction is a condition that occurs when someone has difficulty

reaching orgasm. This difficulty occurs even when they’re sexually aroused and
there’s sufficient sexual stimulation. When this condition occurs in women, it’s
known as female orgasmic dysfunction. Men can also experience orgasmic
dysfunction, but this is much less common.

• Erectile dysfunction, also known as impotence, is defined by difficulty getting

and keeping an erection. It can be an embarrassing thing to talk about. It's been
reported that more than half of men between the ages of 40 and 70 experience
some form of ED. So take comfort in knowing that you are not alone.
• Exhibitionism involves exposing the genitals to become sexually excited or
having a strong desire to be observed by other people during sexual activity.
Exhibitionistic disorder involves acting on exhibitionistic urges or fantasies or
being distressed by or unable to function because of those urges and fantasies.

• Voyeurism involves becoming sexually aroused by watching an unsuspecting

person who is disrobing, naked, or engaged in sexual activity. Common
symptoms of voyeuristic disorder include: Sexual arousal, fantasies, or urges
involving watching an unsuspecting, non-consenting person who is unclothed,
getting undressed, or engaged in sexual acts.

• Frotteuristic disorder, or frotteurism, is a rare and poorly researched type of

paraphilia. It involves the act of touching or rubbing one's genitals against
another non-consenting individual in a sexual manner, to attain sexual
gratification.
• Sexual masochism involves acts in which a person experiences sexual
excitement from being humiliated, beaten, bound, or otherwise abused. Sexual
masochism disorder is sexual masochism that causes significant distress or
substantially interferes with daily functioning. Sexual masochism is a form of
paraphilia.

• Sexual sadism disorder is a mental health-related issue in which a person is

sexually aroused by inflicting physical or emotional pain on another person, and
their sexual urges or behavior causes distress or harm. People with the disorder
may participate in activities that put other people at risk of physical harm.

• Pedophilic disorder is characterized by recurring, intense sexually arousing

fantasies, urges, or behavior involving children (usually 13 years old or
younger). Pedophiles may be attracted to young boys, young girls, or both, and
they may be attracted only to children or to children and adults.

• Fetishistic disorder refers to recurrent, intense sexual arousal from use of an

inanimate object or from a very specific focus on a nongenital body part (or
parts) that causes clinically significant distress or functional impairment in one or
more important areas of life.
• Transvestism involves recurrent and intense sexual arousal from cross-dressing,
which may manifest as fantasies, urges, or behaviors. Transvestic disorder
is transvestism that causes clinically significant distress or functional impairment
in one or more important areas of life.

• Gender dysphoria is a term that describes a sense of unease that a person may
have because of a mismatch between their biological sex and their gender identity.
• This sense of unease or dissatisfaction may be so intense it can lead to depression
and anxiety and have a harmful impact on daily life.

• Gender identity refers to our sense of who we are and how we see and describe
ourselves. Most people identify as "male" or "female". These are sometimes called
"binary" identities. But some people feel their gender identity is different from
their biological sex. For example, some people may have male genitals and facial
hair but do not identify as a male or feel masculine.
• Some may have female genitals and breasts but do not identify as a female or feel
feminine. Some people do not define themselves as having a "binary" identity. For
them the concept of gender is not relevant to their identity.
• Gender dysphoria is the feeling of discomfort or distress that might occur in
people whose gender identity differs from their sex assigned at birth or sex-
related physical characteristics. Transgender and gender-diverse people might
experience gender dysphoria at some point in their lives.

• Symptoms-
• A difference between gender identity and genitals or secondary sex
characteristics, such as breast size, voice and facial hair. In young adolescents,
a difference between gender identity and anticipated secondary sex
characteristics.
• A strong desire to be rid of these genitals or secondary sex characteristics, or a
desire to prevent the development of secondary sex characteristics.
• A strong desire to have the genitals and secondary sex characteristics of
another gender.
• A strong desire to be or to be treated as another gender.
• A strong belief of having the typical feelings and reactions of another gender.
 Causes of sexual dysfunction
• The aetiology of most sexual dysfunction will be multiply determined,
as often both physical and psychological factors are present. Causes can
be split into three broad categories: biological/medical, psychological,
and as a result of sociocultural influences.

• Biological / Medical / surgical conditions that causes sexual dysfunction-

• Endocrine
• ● Diabetes, hyperthyroidism
• ● Addison’s disease, hyperprolactinaemia

• Gynaecological
• ● Vaginitis, endometriosis, pelvic infections

• Cardiovascular
• ● Hypertension, myocardial infarction, peripheral vascular disease
Respiratory
• ● Asthma, obstructive airways disease

Others
• ● Prostate cancer
• ● Arthritis
• ● Renal failure
• ● Pelvic autonomic neuropathy, spinal cord lesions, stroke.

Surgical procedures
• Mastectomy
• Colostomy, ileostomy
• Prostate surgery
• Prolapse surgery
 Some drugs that may impair sexual function
• Therapeutic agents
Diuretics and antihypertensive agents
• ● β- blockers, calcium channel blockers, spironolactone.
Antidepressants and mood stabilizers
• ● SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, lithium
Anxiolytics and hypnotics
• ● Benzodiazepines
Antipsychotics
Antihistamines and histamine H2-receptor antagonists
• ● Diphenhydramine
• ● Ranitidine
Parkinson’s disease medications.
Misused substances
• Alcohol, heroin, amphetamine, MDMA, cocaine, marijuana
• Psychological causes
• Psychological contributions to dysfunction include negative body
image and performance anxiety (fear of negative evaluation, hyper
vigilance, or rejection). Many psychiatric disorders may impair sexual
function. There is a strong relationship with depression, in which rates
of sexual dysfunction are estimated to be up to 50%.

• Sociocultural influences
• Causes of sexual dysfunction can also arise from a person’s social
context. For example communication and relationship inequalities can
foster sexual dysfunction, whilst larger sociocultural influences such
as sex-role or religious proscriptions may also have an impact on
sexual functioning. Furthermore, there are impacts of the environment
under which sexual activity occurs, such as a lack of privacy and
disparate work schedules, which have been identified as significant
contributors to sexual dysfunction.
 DSM-5 – Required Factors
• According to the DSM-5, sexual dysfunction requires a person to feel
extreme distress and interpersonal strain for a minimum of 6 months
(excluding substance or medication-induced sexual dysfunction).
• In addition to the lifelong/acquired and generalized/situational subtypes of
sexual dysfunctions, several factors must be considered during the assessment
of the sexual dysfunction:
 1. Partner factors (their sexual problems, their health status)
 2. Relationship factors (poor communication).
 3. Individual vulnerability factors (poor body image, history of sexual or
emotional abuse)
 4. Cultural or religious factors (inhibitions related to prohibitions against
sexual activity or pleasure; attitudes towards sexuality)
 5. Medical factors relevant to prognosis, course or treatment.
 Assessment of patients with sexual dysfunction
History- taking
• The interviewer needs to be particularly sensitive when enquiring about sexual
function and dysfunction, and when detecting and dealing with embarrassment
experienced by the patient. Whenever possible, the patient and their sexual
partner should be interviewed, both separately and together.

Physical examination and special investigations

• Full physical examination should be performed, in men and in women
separately with full privecy.

Laboratory tests or other investigations should be arranged in appropriate cases—

for example, fasting blood sugar, testosterone, and other hormones in men
with erectile dysfunction.
 Treatment of sexual dysfunction
The first step, after a detailed assessment, is to provide advice and reassurance,
since the problem is often longstanding by the time the patient presents, and
• it may have led to adverse secondary effects. The steps are following:-
1. Advice, information, and reassurance.
2. Treatment of underlying cause.
3. Psychological methods-
• Sexual skills training.
• Sex therapy (including sensate focus exercises).
• CBT.
• Marital therapy.
• Systematic desensitization.
• Educational intervention.
4. Drug treatments
• PDE- 5 inhibitors
5. Other physical treatments
• Vacuum devices
• Dilator
Thanks All