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 article.
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
- Transvestism: persistent, intense arousal related to wearing clothes associated with the opposite sex (crossdressing)
- Transvestic disorder: intense arousal related to wearing clothes associated with the opposite sex that causes clinically significant distress and/or functional impairment. This disorder is a type of paraphilia (not gender dysphoria)
- 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 (typically develops at the age of 3 years)
- Cisgender: an individual whose gender identity aligns with the sex they were assigned at birth
Transgender: an individual whose gender identity does not conform with the sex they were assigned at birth
- May or may not involve medical (e.g., hormone therapy, gender reassignment surgery) or social transition in order to match external appearance with gender identity
- Transgender man: A person who has a masculine gender identity and was assigned a female sex at birth.
- Transgender woman: A person who has a feminine gender identity and was assigned a male sex at birth.
- Transgender people can have any sexual orientation.
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
- Interest in sexual activity
- Manifests as sexual fantasies
- 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.
- Orgasm phase
- The body returns to its physiological baseline.
- 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
- Definition: pain that occurs during or after sexual intercourse
- Commonly associated conditions
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
- Persistent or recurrent difficulty with ≥ 1 of the criteria below in women over a minimum period of 6 months:
- 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)
- 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
- Diagnostic criteria (according to DSM-5)
- Delayed ejaculation, premature ejaculation, and/or erectile disorder: See .
- Female orgasmic disorder: severe delay, infrequency, absence, or reduced intensity of orgasmic sensations for a minimum of 6 months (e.g., anorgasmia)
- 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)
- Medical conditions that can cause similar symptoms to sexual dysfunction and must be ruled out
- Psychological disorders ; (e.g., anxiety, work-related stress, major depressive disorder): suspect in the case of nocturnal penile tumescence is present
- Endocrinopathy; (e.g., decreased testosterone levels, diabetes mellitus, hypothyroidism)
- Nerve damage (e.g., damage to the spinal cord due to trauma or pelvic surgery)
- Ischemia (e.g., atherosclerosis)
- Substance use disorders (e.g., alcohol, heroin)
- Certain drugs (e.g., antihypertensives, antidepressants)
- Individual cognitive-behavioral and psychodynamic 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
- Female orgasmic disorder: education and exercises to enable women to orgasm through self-stimulation
- See ejaculation, premature ejaculation, and/or erectile dysfunction. for treatment of delayed
Differential diagnosis of sexual dysfunction, PENIS: Psychological, Endocrine, Neurogenic, Insufficient blood flow, Substance use.
- 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)
- Abnormally intense and persistent sexual interests occur over a period of at least 6 months
- 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|| |
|Exhibitionistic disorder|| |
|Frotteuristic disorder|| |
|Sexual masochism disorder|| |
|Sexual sadism disorder|| |
|Pedophilic disorder|| |
|Fetishistic disorder|| |
|Transvestic disorder|| |
- 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 child's experienced/expressed gender and assigned gender over a period of at least 6 months, as manifested in ≥ 6 of the following:|
| || |
|Clinically significant distress/impairment in important areas of functioning (e.g., occupation, school)|
- Evaluation by a multidisciplinary team specializing in gender identity
- Hormone therapy
- Gender reassignment surgery
Gender variance itself is not a mental disorder! Possible distress that may follow (dysphoria) is considered a mental disorder.
Sexuality and aging
- ↓ Sensitivity to nipple, vulvar, and clitoral stimulation
- The reproductive capacity of women ends at the beginning of ↓ estrogen → vaginal dryness and atrophy → dyspareunia; treated with hormone replacement therapy and vaginal creams). , which may present with physical changes that affect sexuality (e.g.,
- ↓ Sexual activity
- For more information, see .
- ↓ Amount and quality of sperm
- ↓ Sexual activity
- ↓ Sexual response
- The reproductive ability of males is maintained throughout life; however, functional changes do occur (see ).