• Clinical science

Sexuality and sexual medicine

Summary

Sexual medicine deals with all of the physical and psychological conditions related to sexual health. An individual's sex is defined by their biological features (i.e., sex chromosomes, internal and external genitalia), while gender is based on the attitudes and behaviors that a society or culture typically associates with a specific biological sex. Sexual disorders are characterized by abnormal sexual desires or functioning that cause significant distress and/or impaired social functioning. These disorders may manifest as sexual dysfunction, paraphilic disorders, or gender dysphoria. Physiological aspects of sexuality, such as the sexual response cycle, masturbation, and sexuality in old age, are also discussed in this learning card.

Sex and gender

  • Sex: a collection of biological features, including sex chromosomes and internal and external reproductive organs, that allow an individual to be categorized as male, female, or intersex
  • Sexual orientation: the sex that an individual is physically, romantically, and/or emotionally attracted to
    • Heterosexual: opposite sex
    • Homosexual: same sex
    • Bisexual: opposite and same sex
    • Pansexual: attraction to all kinds of individuals, regardless of their gender, sex, or presentation
    • Asexual: no sexual feelings towards others
  • Transsexual: individuals who have a gender identity different from their sex assigned at birth and desire to live as the opposite sex
  • Gender: the set of socially constructed, culturally-specific attitudes and behaviors deemed appropriate for men and women by a given society
  • Gender identity: an individual's sense of self as male, female, or a combination of both, or neither

References:[1]

Sexual response cycle

The sexual response cycle describes the physiological response to sexual stimulation. In women, individual phases usually last longer than in men and are more susceptible to interference.

The 4 phases of the Whipple and Brash-McGreer sexual response cycle

  1. Desire phase
    • Interest in sexual activity
    • Manifests as sexual fantasies
  2. Arousal phase
    • Excitement phase: initiation of physiological changes
    • Plateau phase: enhanced physiological changes with persistent sexual excitement
  3. Orgasm phase
    • Climatic phase of physical arousal
    • Involuntary muscle contractions in the genital and anal regions
    • : ejaculation
    • : contractions of the proximal labia minora, distal vagina, and uterus
  4. Resolution phase
    • The body returns to its physiological baseline.

References:[2]

Masturbation

  • Definition: manual stimulation of one's own genitals for sexual pleasure
  • Normal activity in men and women of all ages, usually beginning during adolescence
  • Only considered excessive if impaired social or occupational functioning occurs

References:[3]

Sexual dysfunction

Dyspareunia

Disorders

  • Genito-pelvic pain/penetration disorder
    • Diagnostic criteria (according to DSM-5)
      • Persistent or recurrent difficulty with ≥ 1 of the criteria below in women over a minimum period of 6 months:
        • Vaginal penetration during sexual intercourse
        • Severe vulvovaginal or pelvic pain during vaginal intercourse or attempted penetration
        • Severe anticipatory anxiety related to vulvovaginal or pelvic pain during attempted vaginal intercourse or attempted penetration
        • Severe tightening of pelvic floor muscles during attempted vaginal penetration
      • Causes significant distress to the individual
      • Is not attributable to another mental illness, substance, significant relationship distress, or medical condition
    • Precipitating factors
      • Relationship and partner issues (partner's sexual problems, poor communication)
      • Sexual or emotional abuse
      • Poor body image
      • Psychiatric disorders (depression or anxiety) or medical conditions
      • Cultural or religious influences (negative attitudes toward sexuality)
    • Treatment
      • Pelvic floor physical therapy: considered best initial treatment option; ; consists of a combination of modalities, as internal manual techniques, patient education, dilatation exercises, local tissue desensitization, and home exercises.
      • Anxiolytic drugs: in conjunction with other therapeutic modalities
      • Local botox injections for refractory cases
  • Delayed ejaculation, premature ejaculation, and/or erectile disorder: See erection and ejaculation disorders.
  • Female orgasmic disorder: severe delay, infrequency, absence, or reduced intensity of orgasmic sensations for a minimum of 6 months
  • Female sexual interest/arousal disorder: absent/reduced interest in sexual activity, sexual thoughts, initiation or participation in sexual activities, sexual excitement/pleasure in most sexual encounters, sexual arousal to sexual cues, genital or nongenital sexual sensations during most sexual encounters for a minimum of 6 months
  • Male hypoactive sexual desire disorder: persistent or recurrent deficiency or absence of sexual thoughts and desire for sexual activity for a minimum of 6 months
  • Medication-induced sexual dysfunction: : severe disturbance in sexual function that occurs during or soon after substance intoxication or withdrawal, or after exposure to a medication that is capable of causing symptoms of sexual dysfunction (e.g., SSRIs, antipsychotics)

Treatment

The most common disorders in women are sexual interest/arousal disorder and female orgasmic disorder, while the most common disorders in men are erectile disorder and premature ejaculation.

Differential diagnosis of sexual dysfunction, PENIS: Psychological, Endocrine, Neurogenic, Insufficient blood flow, Substance use.

References:[4][3]

Paraphilic disorders

  • Definition: : characterized by abnormally intense and persistent sexual interests; (manifested as urges, fantasies, or behaviors) accompanied by significant distress or functional impairment of the affected individual
  • Diagnostic criteria (according to DSM-5)
    1. Abnormally intense and persistent sexual interests occur over a period of at least 6 months
    2. Result in significant distress or impairment in important areas of functioning (e.g., social, occupational) to the individual or they harm or have the potential to harm others (e.g., children, nonconsenting adults).
Additional disease-specific criteria
Voyeuristic disorder
  • Persistent and intense sexual arousal caused by observation of an unsuspecting person who is nude, undressing, or engaging in sexual activity
  • The patient must be ≥ 18 years of age.
Exhibitionistic disorder
  • Persistent and intense sexual arousal caused by exposure of one's genitals to an unsuspecting person
Frotteuristic disorder
  • Persistent and intense sexual arousal caused by touching or rubbing against a nonconsenting person
Sexual masochism disorder
  • Persistent and intense sexual arousal caused by being beaten, bound, humiliated, or made to suffer
Sexual sadism disorder
  • Persistent and intense sexual arousal caused by inflicting pain, suffering, or humiliation on another person
Pedophilic disorder
  • Persistent and intense sexual arousal occasioned by prepubescent child or children (≤ 13 years of age)
  • The patient is at least 16 years old and at least 5 years older than the child/children.
Fetishistic disorder
  • Persistent and intense sexual arousal related to, and a fixation on, nonliving objects (e.g., shoes) or nongenital parts of the body (e.g., feet, hair)
  • Criteria of exclusion: Sexual arousal is limited to sex toys and/or clothing used for cross-dressing.
Transvestic disorder
  • Persistent and intense sexual arousal caused by wearing clothes associated with the opposite sex

Transvestic disorder is not always associated with homosexuality.

References:[4][3]

Gender dysphoria

  • Definition: distress caused by an incongruity between a person's experienced/expressed gender and assigned gender
Diagnostic criteria (according to DSM-5)
Gender dysphoria in children Gender dysphoria in adolescents and adults
An incongruence between a person's experienced/expressed gender and assigned gender over a period of at least 6 months, as manifested in ≥ 6 of the following:

An incongruence between a person's experienced/expressed gender and assigned gender over a period of at least 6 months, as manifested in ≥ 2 of the following:

  1. Strong desire to be the other gender
  2. In boys, a strong desire to wear typical girls' clothing; in girls, a strong desire to wear typical boys' clothing
  3. Strong desire for cross-gender roles during make-believe play
  4. Strong preference for toys and activities typically associated with the other gender
  5. Strong preference for playmates of the other gender
  6. Strong rejection of typically masculine toys and activities in boys; rejection of typically feminine toys and activities in girls
  7. Strong dislike of one's own sexual anatomy
  8. Strong desire for the primary and/or secondary sex characteristics that correspond with the desired gender
  1. Incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics
  2. Strong desire to be rid of one's primary and/or secondary sex characteristics
  3. Strong desire for primary and/or secondary sex characteristics of the other gender
  4. Strong desire to be the other gender
  5. Strong desire to be treated as the other gender
  6. Strong conviction that one has feelings and behaviors more typical of the other gender
Clinically significant distress/impairment in important areas of functioning (occupation, school)

References:[4][5][3]

Sexuality and aging

Female sexuality

Male sexuality

  • ↓ Amount and quality of sperm
  • ↓ Sexual activity
  • ↓ Sexual response
  • The reproductive ability of males is maintained throughout life; however, functional changes do occur (see erection and ejaculation disorders).

References:[6]

  • 1. American Psychological Association. APA LGBT Resources and Publications - General Audience Resources - Definitions of Terms in APA Documents Related to Sexual Orientation and Gender Diversity . http://www.apa.org/pi/lgbt/resources/index.aspx. Updated January 1, 2015. Accessed July 3, 2017.
  • 2. Association of Reproductive Health Professionals. Clinical Facts Sheet: Female Sexual Response. http://www.arhp.org/publications-and-resources/clinical-fact-sheets/female-sexual-response. Updated March 1, 2008. Accessed June 4, 2018.
  • 3. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psychiatry. New York, NY: Wolters Kluwer Health; 2014.
  • 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). . 2013. doi: 10.1176/appi.books.9780890425596.
  • 5. American Psychological Association. Practice Guidelines for LGB Clients - Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. http://www.apa.org/pi/lgbt/resources/guidelines.aspx. Updated February 20, 2011. Accessed June 3, 2017.
  • 6. Taylor A, Gosney MA. Sexuality in older age: essential considerations for healthcare professionals. Age Ageing. 2011; 40(5): pp. 538–543. doi: 10.1093/ageing/afr049.
last updated 12/05/2019
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