• Clinical science

Sexuality and sexual medicine

Abstract

Sexual medicine deals with all 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
  • Gender: : the set of socially constructed, culturally-specific attitudes and behaviors associated with biological sex ; the set of socially constructed, culturally-specific attitudes and behaviors deemed appropriate for men and women by a given society
  • Sexual orientation: the sex that an individual is sexually and romantically attracted to
    • Heterosexual: opposite sex
    • Homosexual: same sex
    • Bisexual: attraction to the opposite and same sex
  • Transsexual: : an individual who has undergone social (and often legal) transition to the opposite sex, which may include hormone therapy and genital surgery
  • Gender identity: an individual's sense of self as male, female, or transgender
  • Transgender: an umbrella term to describe individuals whose gender identity does not conform to the sex they are assigned at birth

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.

  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
      • : Increased blood flow from the prostate and seminal vesicle leads to increased secretion of the bulbourethral gland and urethral glands; pre-ejaculate (watery, viscous discharge at the external urethral orifice)
      • : Increased secretion from the Bartholin glands leads to the increased production of vaginal transudate (lubrication), increased blood flow to the vagina, and expansion of the labia majora.
  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

  • Individual cognitive behavioral and psychodynamic therapy
  • Sex therapy
    • Short-term therapy for individuals or couples
    • Addresses psychological and physical barriers to a healthy sexual relationship
    • Involves exercises to increase sexual sensory awareness and progressively heighten levels of sexual contact
  • Pharmacotherapy
    • Male hypoactive sexual desire disorder: testosterone replacement therapy
    • Female sexual interest/arousal disorder: low-dose testosterone and/or vaginal estrogen replacement therapy (post-menopausal women)
  • Mechanical therapy
    • Female orgasmic disorder: education and exercises to enable women to orgasm through self-stimulation
  • See erection and ejaculation disorders for treatment of delayed ejaculation, premature ejaculation, and/or erectile dysfunction.

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!

References:[4][3]

Paraphilic disorders

  • Definition: : characterized by abnormally strong and persistent sexual interests; (manifested as urges, fantasies, or behaviors) accompanied by significant distress or impairment of functioning to the individual or others
  • Diagnostic criteria (according to DSM-5)
    1. 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 the individual acted on these sexual interests with a nonconsenting person
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 (gender identity) 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 girls' clothing; in girls, a strong desire to wear typical masculine clothing exclusively
  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)
  • Treatment
    • Psychotherapy
    • Hormone therapy
    • Sexual reassignment surgery

References:[4][5][3]

Sexuality and aging

Female sexuality

  • Sexual interest does not usually decline with age.
  • ↓ Sensitivity to nipple, vulvar, and clitoral stimulation
  • The reproductive capacity of women ends at the beginning of menopause, which may present with physical changes that affect sexuality (e.g., estrogen → vaginal dryness and atrophydyspareunia; treated with hormone replacement therapy and vaginal creams).
  • For more information, see menopause.

Male sexuality

  • ↓ Amount and quality of sperm
  • ↓ Sexual activity
  • ↓ Sexual response
  • Sexual interest does not usually decline with age.
  • The reproductive ability of males is maintained throughout life; however, functional changes do occur (see erection and ejaculation disorders).

References:[6]

last updated 11/19/2018
{{uncollapseSections(['WKcP2W0', 'VKcG2W0', 'dKco2W0', 'fKckfW0', '2KcTfW0', 'pKcLhW0', 'JKcshW0', 'eKcx2W0'])}}