Human Sexuality and Sexual Dysfunction

• Sexuality is an essential aspect of all stages of human life, ensuring the continuity of humanity.
• It is a key determinant of the quality of life of humans.
• The word ‘sexuality’ was first used in 1800 in relation to sex as a reproductive function in both plants and animals.
• However, it was not until 1889 that it was exclusively used for the capability of sexual feelings in humans.

• Sexuality may be defined as the feelings and activities connected with a person’s sexual desires.
• The way people experience and express themselves sexually.
• Comprises sexual desire, arousal, function and activity, physical satisfaction, and emotional intimacy.

Trichotomy Of Sexuality

• Proposed by Ollis et al in 2001.
• It provides a holistic model that impacts on our sexual formation.
• The model explains the integration of:

• Sexual orientation: who we are attracted to.
• Sexual identity: how one thinks of oneself in terms of to whom one is attracted.
• Sexual behavior: the sexual contacts we have.

This interaction may not be fully expressed and may change over time.

Can be grouped into 3 classes:

1. Sex
2. Gender
3. Sexual orientation

1. Sex
• Refers to the anatomic makeup of an individual.
• This is defined based on external genitalia, internal reproductive organs, and the sex chromosomes.
• There can, however, be a mismatch such as in androgen insensitivity syndrome, mosaicism, and intersex.
2. Gender
• Refers to the sexual view of oneself, such as being male, female, both, neither, or mixed.
• Can be classified into the following:
1. Cis-gender: Same gender with sex assigned at birth.
2. Trans-gender: Gender is different from biological sex.
3. Genderqueer/Non-binary: Identity does not conform to the traditional binary gender paradigm.
4. Gender fluid: Gender identity is not fixed. Varies with time and/or situation.
3. Sexual orientation
• Refers to sexual attractions/preference.
• Includes being straight, homosexual, bisexual, pansexual, omnisexual, and asexual.

Sexual disorders are problems with sexual activities that cause a person or couple psychological distress and are generally divided into 4 categories (ICD-10):

1. Gender identity disorders/dysphoria
2. Paraphilias
3. Psychological and behavioral disorders associated with sexual development and orientation
4. Sexual dysfunctions

Gender Identity Disorders/Dysphoria

• Refers to people whose gender at birth is contrary to the one they identify with.
• Characterized by clinically significant distress or impairment of social/occupational/other important areas of functioning, due to marked incongruence between the patient’s expressed gender and his/her assigned gender at birth, lasting for at least 6 months and must include at least 2 of the following 6 criteria:
1. Marked incongruence between the expressed gender and the primary/secondary sexual characteristics.
2. Strong desire to be rid of his/her primary/secondary sexual characteristics (in the young, to prevent its development).
3. Strong desire for the sexual characteristics (primary/secondary) of the other gender.
4. Strong desire to be of the other gender.
5. Strong desire to be treated like the other gender.
6. Strong conviction of having the typical feelings and reactions of the other gender.

Paraphilias

• Refers to any intense and persistent sexual interest, other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners.
• Paraphilic disorder: when paraphilia causes distress/impairment to the individual or if the satisfaction involves personal harm/risk of harm to others.
• Commonly observed paraphilic disorders include the following:
• Voyeuristic Disorder: This is a condition where a person gets sexually aroused by observing someone in a sexual act who does not realize they are being watched.
• Exhibitionistic Disorder: This disorder involves sexual arousal from genital exposure to an unsuspecting person or a strong desire to be observed by others.
• Frotteuristic Disorder: This is characterized by recurrent and persistent sexual arousal from touching or rubbing against a nonconsenting person, usually a stranger.
• Sexual Masochism Disorder: This condition involves experiencing recurring and intense sexual arousal in response to enduring moderate or extreme pain, suffering, or humiliation.
• Sexual Sadism Disorder: This disorder is characterized by experiencing sexual arousal in response to the involuntary extreme pain, suffering, or humiliation of others.
• Pedophilic Disorder: This is characterized by a primary or exclusive sexual attraction to prepubescent children.
• Fetishistic Disorder: This disorder involves persistent sexual excitement stemming from fantasies, urges, or behavior related to causing physical or psychological harm to another during sexual activity.
• Transvestic Disorder: This involves recurrent, intense sexual arousal from cross-dressing.
• Necrophilia: This is a paraphilia characterized by a sexual attraction to corpses.
• Zoophilia: This is a sexual attraction of a human toward a nonhuman animal.
• Coprolalia: Coprolalia is a disorder characterized by the involuntary and repetitive use of obscene language or socially inappropriate words and phrases.
• Coprophilia: Coprophilia is a sexual paraphilia involving an abnormal interest in feces. Individuals with coprophilia may be aroused by the sight, smell, or taste of feces, or may enjoy incorporating feces into sexual activities.
• Urophilia: Urophilia is a paraphilia involving sexual arousal from urine or urination. Individuals with urophilia may be aroused by watching someone urinate, being urinated on, or urinating on another person.

Psychological & Behavioral Disorders of Sexual Development and Orientation

• No agreed theory on disordered sexual orientation till date. However, In 1988, Troiden published a framework for understanding the developmental processes of patients:

Troiden's Framework:

1. Sensitization
2. Identity confusion
3. Identity assumption
4. Commitment

Sexual Dysfunction

• The most prevalent of the disorders in clinical practice.
• Refers to a difficulty experienced during any phase of the sexual response cycle that prevents an individual or couple from experiencing satisfaction from sexual activity.
• Includes disorders of Desire, Arousal, and Orgasm. There might also be an overlap.

• Sexual response cycle is divided into 4 phases:
• Excitement
• Plateau
• Orgasm
• Resolution

Phase 1: Desire/Excitement

• Occurs in response to erotic stimuli.
• Increase in heart rate, blood pressure, and respiratory rate while muscles tense.
• The male's testicles swell, his scrotum tightens.
• Breasts become fuller and nipples become hardened or erect.
• Blood flow to the genitals increases, resulting in swelling of the woman's clitoris and labia minora (inner lips), and vaginal swelling and lubrication begins. Erection of the male's penis occurs.

Phase 2: Plateau

• Both males and females experience powerful surges of sexual excitement or pleasure.
• The changes at excitement are intensified.
• Breathing, heart rate, and blood pressure increase.
• Muscle tension and spasm increase.
• The man's testicles are withdrawn up into the scrotum, erection hardens and lengthens.
• The vagina continues to swell from increased blood flow while the clitoris becomes more sensitive.

Phase 3: Orgasm

• Climax of sexual response cycle.
• Involuntary muscle contractions begin.
• In women, the muscles of the vagina and uterus undergo rhythmic contractions.
• In men, rhythmic contractions of the muscles at the base of the penis result in the ejaculation of semen.
• Blood pressure, heart rate, and breathing are at their highest rates.
• Muscles in the feet spasm.

Phase 4: Resolution

• The body slowly returns to its normal level of functioning.
• Swelled and erect body parts return to their previous size and color.
• General sense of well-being, enhanced intimacy, often fatigue.

• Difficulties that occur during the sexual response cycle that prevent the individual from experiencing satisfaction from sexual activity.
• Can occur at one or more of the phases of the sexual cycle.
• To be considered dysfunctional, the symptoms must cause distress and must occur at least 75% of the time over a 6-month period.
• Can affect the quality of life of patients with resultant consequences such as infidelity, STIs, marital disputes, and broken homes.
• Often underestimated in Nigeria.

Classification of Sexual Dysfunction

MALE

• Desire/Interest Disorder
• Arousal Disorder
• Orgasmic Disorder
• Pain/Penetration Disorder

FEMALE

• Desire/Interest Disorder
• Arousal Disorder
• Orgasmic Disorder
• Genito-Pelvic Pain/Penetration Disorder

Sexual Desire Disorder

Hypoactive Sexual Desire Disorder

It is characterized by a persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activities.

Sexual Aversion Disorder

Persistent or recurrent extreme aversion to, and avoidance of all sexual contacts with a sexual partner.

Arousal Disorder

Female Sexual Arousal Disorder

• Persistent or recurrent partial or complete failure to attain or maintain the lubrication swelling response.
• Persistent Genital Arousal Disorder: spontaneous, intrusive, and unwanted genital arousal unrelieved by one or more orgasms.

Male Erectile Disorder

Persistent or recurrent inability to attain or maintain an erection to perform a satisfactory sexual act.

Female Orgasmic Disorders

• Absence or recurrent difficulty in attaining orgasm after sufficient sexual stimulation.
• Can be primary or secondary.
• Many women achieve arousal but not orgasm.

Female Orgasmic Disorder (Proposed DSM-5 Criteria)

• On most occasions of sexual activity for at least 6 months:
• Marked delay, infrequency, or absence of orgasm
• Markedly reduced intensity of orgasmic sensation
• Causes marked distress or interpersonal problems
• Not due to a medical illness, another psychological disorder (except another sexual dysfunction), or the effects of a drug

Male Orgasmic Disorders & Premature Ejaculation

• Disorders of ejaculation are commonly experienced by men.
• Anorgasmia: inability to reach orgasm or ejaculate despite adequate sexual stimulation.
• Delayed Orgasm: excessively prolonged time before orgasm, often lasting 30 minutes or more.
• Retrograde Ejaculation: ejaculation into the bladder.
• Premature Ejaculation: ejaculation before or shortly after penetrating the vagina.

Genitopelvic Pain/Penetration Disorder

• More prevalent in women. Could be superficial (occurs with attempted penetration) or deep pain (related to thrusting).
• 2 types:
1. Dyspareunia:
   • Recurrent or persistent genital pain associated with sexual intercourse.
   • Can be from psychological or physical factors.
   • Can be primary/secondary, complete/situational.
   • Superficial Causes in Women:
   • Vaginal infections, vaginal atrophy, vaginitis.
2. Vaginismus:
   • Involuntary contraction of muscles of the outer one-third of the vagina. Often related to sexual phobias or past abuse.
   • Can be complete or situational.
   • Deep Causes in Women:
   • Cervicitis, PID, endometriosis, ectopic pregnancy.
   • In Men:
   • Damage to foreskin, STIs, priapism, etc.

Vaginismus

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Vaginismus

Genitopelvic Pain/Penetration Disorder (Proposed DSM-5 Criteria)

• Persistent or recurrent difficulties for at least 6 months with one of the following:
1. Marked difficulties with vaginal penetration during intercourse
2. Marked pain during intercourse
3. Marked fear or anxiety about pain or penetration
4. Marked tensing or contraction of pelvic floor muscles during intercourse
• Causes marked distress or interpersonal problems.

• Can be classified as Biological, Psychological, or Environmental factors.
• Biological factors:
  • Serotonin/Dopamine balance
  • Medical conditions (such as Arthritis, CLD, CKD, immunosuppression, Pregnancy)
  • Substance abuse, drugs (hormonal preparations, psychotropics, antihypertensives, etc.)
• Psychological factors:
  • Stress, anxiety
  • Religious taboos
  • Depression, guilt
  • Past sexual trauma
• Environmental factors:
  • Age, educational level
  • Parity
  • Religious taboos
  • Traditional customs
  • Marital disputes

History

GRIPS

• Biodata
• Address FIFE (Feelings, Ideas, Function, Expectations)
• Medical History
• Surgical History
• Gynaecology/Obstetrics History
• In-depth Family History
• Social History
• Drug History

Why Sexual History?

• It provides an opportunity to give advice about prevention of sexually transmitted diseases including HIV and Hepatitis.
• Disrupted sexual function may be a symptom of a disease or a side effect of treatment.
• Past sexual history may help explain the present condition.
• Sexual issues are important at all stages of the life cycle.
• Sexual dysfunctions are common.
• Sexual function is related to good health.
• Sexual dysfunction is an important determinant of family dynamics.

Components of a Good Sexual History

• A - Adopt a non-judgemental attitude and no assumptions.
• B - Be calm and relaxed.
• C - Confidentiality must be assured.
• D - Direct and simple language.
• E - Encourage questions from the patient and provide explanations.
• F - Follow the interviewing approaches as appropriate:
• Inclusion: 'routinely asked'
• Normalization: 'prevalent - you are not alone'
• Universalization: 'everyone has done everything. Not unique to you'

Barriers to Discussing Sexual Health

• Concerns about competence and expertise; training in the management of sexual health at both undergraduate and postgraduate levels have been deemed inadequate. This tends to make the physicians feel that it is unfair to probe into an area that they are ill-equipped to manage.
• Fear of embarrassment to the doctor and patient; quite common especially with the opposite gender.
• Fears of opening a ‘floodgate’ or ‘can of worms’.
• Time constraint.
• Patients fear that they may lose the respect of their physicians if they initiate the discussion.
• Fear of loss of self-esteem by the patients in addressing what is generally taken to be a ‘private issue’.

Physical Examination

• Do a general physical examination.
• Do a full systemic examination.
• Mental state examination where necessary.
• Examine the thyroid, the breasts, and the skin.
• Examine the anorectal areas.
• Examine the external genitalia.
• Vaginal examination.

Investigations

Rarely Helpful

Males	Females
FBC + ESR Serum testosterone: total and free Sex hormone binding globulin (SHBG) Thyroid function test LFT Renal function tests FLP FBG	FBC + ESR Thyroid function test LFT Renal function tests Serum Oestradiol FSH levels Prolactin level LH levels FBG

Treatment

• Complicated by the lack of a single causative factor.
• Limited proven treatment options.
• Physician unfamiliarity with available treatments.
• Patient education and therapy are the foundation of treatment.

GENERAL MEASURES

• Sex education
• Relaxation exercises
• Behavioral measures

SPECIFIC MEASURES

• Pharmacological measures
• Non-pharmacological measures
• Combination of the above
• Use of alternative medicines

Sex Education

BASIC AREAS TO COVER

• Discussion about the anatomy of sex organs and normal sexual response.
• Educate the patient/couple about the wide variation in the extent and frequency of feelings of sexual desire from one individual to the next.
• Educate patient/couple about the importance of the timing of sex.
• Educate patient/couple about the fact that sexual desire levels fluctuate over the life span.
• Encourage patient/couple to communicate their needs for desire and sexual arousal.

CLARIFY MYTHS

• All physical contact must lead to sex.
• Good sex leads to wild orgasms.
• All other couples have sex several times a week; have orgasm every time they have sex & orgasm simultaneously.
• Penile size: the bigger the better.
• Intercourse: the longer the better.
• Most women have orgasm from vaginal intercourse.
• Women do not want sex as men do.
• As long as a couple love each other, they know how to give pleasure in lovemaking.
• No intercourse during pregnancy and after menopause.

Hypoactive Sexual Desire Disorder

Non-Pharmacologic Therapy

• Counseling: lifestyle changes such as stress management, adequate rest, and regular exercise.
• Behavioral changes: couple communication, sex therapy, psychotherapy.

Pharmacologic Treatment

• Often limited.
• Supplemental testosterone may be helpful.

Sexual Arousal Disorder

Female

• Counselling
• Behavioural therapy
• Phosphodiesterase (PDE) 5 inhibitors
• Eros Clitoral Therapy Device

Eros Clitoral Therapy Device

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Eros Clitoral Therapy Device

Males

• Counseling
• Behavioural/sex therapy
• Intraurethral/ intracavernosal Alprostadil
• Penile Prostheses
• Vacuum pump
• Penile revascularization
• Phosphodiesterase-5-inhibitors

intracavernosal Alprostadil

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intracavernosal Alprostadil

Penile Prostheses

×

Penile Prostheses

Vacuum pump

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Vacuum pump

Orgasmic Disorder

Female

• Anorgasmia has been successfully treated with:
• Directed masturbation
• Cognitive behavior therapy
• Sensate focus therapy
• Kegel exercises
• Eros CTD
• Individual or couple’s sex therapy
• Bupropion
• PDE 5 inhibitors

Male

Premature ejaculation:

• Pause-squeeze/start-stop techniques
• Condoms
• Local anaesthetics

Anorgasmia:

• Behavioural/sex therapy
• Psychotherapy
• Discontinue offending drug
• Testosterone supplements
• Anti-depressants
• Cyproheptadine

Sexual Pain Disorders

• Addressing the underlying cause is the first step in treatment.
• Lubricants
• Hormone replacement therapy
• Physiotherapy (pelvic floor exercises) - Kegel exercise
• Use of vaginal dilators
• Psychotherapy
• Cognitive behavior therapy (provided in a group setting over six months)

Dilators

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Dilators

Benefits to doing Kegel exercise

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Benefits to doing Kegel exercise

Complementary and Alternative Medicine in Treatment of Sexual Dysfunctions

Mind and Body Practices:

• Acupuncture
• Yoga
• Meditation

Herbal Supplements:

• Yohimbe bark (Pausinystalia yohimbe)
• Ginseng (Panax ginseng - Korean Red Ginseng)
• Ginkgo (Ginkgo biloba)
• Nutmeg (Myristica fragrans)

Nutritional Supplements

• Arginine
• Folic acid
• Zinc
• Vitamin E
• Food, fruits, and nuts

• Sexuality is complex, with a wide range of normal functioning.
• Dysfunction can be difficult to classify and may be a normal adaptive variant, which is often dependent on the sexual partner.
• Changes over a patient’s lifetime will be associated with alteration of sexual function, and it is important for all health professionals to be aware of these factors and interventions that can help alleviate distress.
• Detailed history of the patient (+/- partners) is all that is required in most cases to make a diagnosis.
• Doctors should therefore acquaint themselves with knowledge of sexuality.