By:

DR AINI SIMON
 SEXUAL DEVELOPMNET
Prenatal physical sexual development
 Differentiation of the gonads is dependent on the presence or absence of the Y
chromosome, which contains the testis-determining factor gene.
 The androgenic secretions of the testes direct the differentiation of male internal
and external genitalia.
a. In the absence of androgens during prenatal life, internal and external
genitalia are female.

b. In androgen insensitivity syndrome (formerly testicular feminization), despite

an XY genotype and testes that secrete androgen, a genetic defect prevents the
body cells from responding to androgen, resulting in a female phenotype. At
puberty, the descending testes may appear as labial or inguinal masses.
c. In the presence of excessive adrenal androgen secretion prenatally (congenital
viriliz­ing adrenal hyperplasia; formerly adrenogenital syndrome), the genitalia of
a genetic female are masculinized and the child may be identified initially as
male.
Hormones and sexual behavior

 Generally substance that increase dopamine

levels in brain INCREASE desire and subtance
that augment serotonin DECREASE desire.
 Testosterone increase libido in both.
 Progesterone mildly decrease desire as do
excessive prolactin and cortisol.
 Oxytocin is involve in pleasurable sensations
during sex.
 Biology of Sexuality in Adults
In adults, alterations in circulating levels of gonadal hormones (estrogen, progesterone,
and testosterone) can affect sexual interest and expression.
A. Hormones and behavior in women
 Because estrogen is only minimally involved in libido, menopause (i.e., cessation of
ovar­ian estrogen production) and aging do not reduce sex drive if a woman's general
health is good.
 Testosterone is secreted by the adrenal glands (as well as the ovaries and testes)
through­out adult life and is believed to play an important role in sex drive in both
men and women.
B. Hormones and behavior in men.
- Testosterone levels in men generally are higher than necessary to maintain normal
sexual functioning; low testosterone levels are less likely than relationship problems,
age, or unidentified illness to cause sexual dysfunction.
 Psychological and physical stress may decrease testosterone levels.
 Medical treatment with estrogens, progesterone, or antiandrogens (e.g., to treat
prostate cancer) can decrease testosterone availability via hypothalamic feedback
mechanisms, resulting in decreased sexual interest and behavior.
Gender and sexuality

 Men
 Think more about sex
 Want more sex
 Want more and have more partners
 Have more sexual dysfuction as they age
 Women
 Desire for sex more often linked to relationship
status and social norms
 At all ages, women more likely to report
sexual dysfunction as compared to men.
 The Sexual Response Cycle
 1. Masters and Johnson devised a four-stage model for
sexual response in both men and women, including the
 Desire-sexual fantasies and the desire to have sexual activity
 Excitement-sense of pleasure
 Orgasm-peaking of sexual pleasure
 Resolution-back to resting state
 2. Sexual dysfunctions involve difficulty with one or
more aspects of the sexual response cycle and can
overlapped.
Male Sexual Anatomy
Female Sexual Anatomy
 Sexual Gender And Identity
Disorder

Sexual Dysfunction Sexual Dysfunction 2 Gender Identity Sexual

GMC/Substance abuse Sexual Dysfunction Paraphilias
NOS Disorder Disorder
NOS

Fethishim
Desire

Arousal pedophilia

Orgasm Sadism

Pain Voyeurism
Diagnosis

 Must cause marked distress or interpersonal

difficulty to person life
 Specifiers
 Lifelong(primary) vs acquired (secondary)
 Global vs situational
 Gradual vs sudden
 Differentiate from secondary to a medical or
psychiatric condition
 Physical disease
 Substance abuse
 Medication
 SEXUAL DYSFUNCTIONS
Sexual dysfunction can result from biological, psychological, or interpersonal causes,
or from a combination of causes.
 a. Biological causes include an unidentified general medical condition (e.g.,
diabetes can cause erectile dysfunction; pelvic adhesions can cause
dyspareunia), side effects of medication [e.g., selective serotonin reuptake
inhibitors (SSRIs) can cause delayed orgasm], substance abuse (e.g., alcohol use
can cause erectile dysfunction), and hormonal or neurotransmitter alterations.

 b. Psychological causes include current relationship problems, stress,

depression, and anxiety (e.g., guilt, performance pressure). In men with erectile
disorder, the presence of morning erections, erections during masturbation, or
erections during rapid eye movement (REM) sleep suggests a psychological
rather than a physical cause.

 2. Dysfunctions may always have Been present (primary sexual dysfunctions), or,
more commonly, they occur after an interval when function has been normal
(secondary sexual dysfunctions).
 CLASSIFICATIONS OF SEXUAL DYSFUNCTION
By PHASE OF SEXUAL CYCLE
 The sexual desire disorders are
 hypoactive sexual desire disorder
 sexual aversion disorder (disorders of the excitement phase).

 The sexual arousal disorders are

 female sexual arousal disorder
 MALE ERECTILE DISORDER (disorders of the excitement and plateau phases).

 The orgasmic disorders are

 male orgasmic disorder,
 female orgasmic disorder,
 PREMATURE EJACULATION (disorders of the orgasm phase).

 The sexual pain disorders are

 dyspareunia
 vaginismus (not due to a general medical condition).

DSM-IV-TR
Sexual Desire Disorders

 Hypoactive sexual desire disorder

 Deficient or absent sexual fantasies and urges
 Low sex drive

 Sexual aversion disorder

 Individual actively avoids nearly all genital contacts
with another person
 ‘sexual phobia’
 Classically conditioned response
 assault + sex = fear, panic avoidance
Sexual Arousal Disorder
 Female
 Consistently inadequate vaginal lubrication for comfortable
completion of intercourse
 Male
 Most common is Erectile Dysfunction
 Persistent failure to attain or maintain an erection through
completion of the sexual activity
 Theory: pressure on pudendal artery in the glands penis can
lead to ED
 Dettori, 2004: study 463 cyclists 320km race
 4.2% had ED 1 week later
 1.8% had ED 1 month later
Orgasmic Disorder
 Female Orgasmic Disorder
 Absence of orgasm after sexual excitement
 Male Orgasmic Disorder
 Persistent difficulty ejaculating
 Is this really a problem?....
 >>> YES.
 It is associated with low self confidence in men
 Women report fear that the partner is unfaithful
Premature Ejaculation
 Ejaculation that occurs too quickly
 Ejaculation before the man would like it to occur
 Plateau phase of the sexual response cycle is short or absent
 Is usually accompanied by anxiety
 The most common male sexual disorder
 How early?
 In large studies shows that time take to ejaculate 7-14min
 Germany- 7min
 US-13.6min
 England, France, Italy-9.6min
 Hypothesis
 Low levels of serotonin >> less activation at 5-HT
receptor>>lowers ejaculatory set point.
Sexual Pain Disorder
 Dyspareunia
 Persistent or recurrent pain during intercourse
 Diagnosable in both men and women
 In woman most common is vulva vestibulitis syndrome
(VVS) in 15-21%
 Vaginismus
 Involuntary spasm of the outer third of the vagina
 Prevent penetration
 Sexual pain in men
 Can take place during erection, intromission, thrusting
or ejaculation
 Likely due to PROSTATITIS
 Allergic to spermicidal creams
 Poor hygiene in uncircumcised men
 Priapism- persistent abnormal erection of the
penis, accompanied by pain and tenderness
 Commonly associated with antipsychotic use
 Predisposing factors
contributing to sexual
Biologic
dysfunction
 Endocrine disorders (hypoandrogenism, hypoestrogenism,
hyperprolactinemia, adrenal dysfunction, thyroid dysfunction, diabetes)
 Recurrent vulvovaginitis and/or cystitis
 Pelvic floor disorders: lifelong or acquired
 Drug treatments affecting biovailability of sex steroids or
neurotransmitter levels
 Chronic diseases (cardiovascular, neurologic or psychiatric diseases, and
so on)
 Benign diseases (e.g. endometriosis) predisposing to iatrogenic
menopause and dyspareunia
 Persistent residual conditions (e.g. dyspareunia/chronic pain associated
with endometriosis)

Graziottin et al (2006)
Psychosexual
 Inadequate/delayed psychosexual development
 Borderline personality traits
 Previous negative sexual experiences: sexual
coercion, violence, or abuse
 Body image issues/concerns
 Affective disorders (dysthymia, depression, mania)
and anxiety disorders
 Inadequate coping strategies
 Inadequate sexual education

Graziottin et al (2006)
Contextual
 Ethnic/religious/cultural messages, expectations,
and
 constraints regarding sexuality
 Social ambivalence towards sexual activity, when
separated from reproduction or marriage
 Negative social attitudes towards female
contraception
 Low socioeconomic status/reduced access to
medical care and facilities
 Support network

Graziottin et al (2006)
 TREATMENT FOR SEXUAL
DYSFUNCTION
 1. The physician must understand the patient's sexual problem
before proceeding with treatment (e.g., clarify what a
patient means when he says, "I have a problem with sex.").

 2. The physician should not assume anything about a patient's
sexuality (e.g., a middle-aged married male patient may
be having an extramarital homosexual relationship).

 3. Treatment of sexual problems may be behavioral, medical or

surgical.

TREATMENT
Psychological treatment :
Sensate Focus
 Developed by Masters and Johnson
 Stage 1 – touch body (no genitals or breast) with
goal of increasing awareness
 Limited touching
 Ignore arousal
 Stage 2
 Touching all over
 ‘receiver’ guides hand of ‘toucher’
  Stage 3
 Mutual touching that feels natural
 Begin to shift attention away from own body onto
partner’s
 Stage 4
 Increase genital touching with goal of arousal
 Proceed to intercourse when ready
 Therapy 2-3X/week
 Failure rates very low (maximum 20%)
 Relapse rates 5%
Cognitive Behavioral Therapy

 Combination of cognitive therapy

(challenging maladaptive sexual believes and
behavioral therapy (exercise) and education
Couple Therapy

 Communication training
 Marital Therapy
 Problem solving
 Assertiveness training
 Examining the ‘system’- how does the
dysfunction keep the relationship balanced?
Physical Treatment

 Dilators for vaginismus

 Vacuum Erection Devices

 Tube placed over flaccid penis
 Automatic and manual pump draws blood into
penis
 Rubber band placed over base of erect penis to
maintain erection
 Stop-start technique
 Partner manually stimulates until erection
 Either stop stimulation or squeeze the prepuce
(muscle under head of penis)
 Extends foreplay and teaches ejaculatory control
 Intracarvenosal injections for ED
 Prostaglandin E1 (Alprostadil)-no sexual
stimulation is needed to relax muscle
 Transurethral therapy
Medications for ED
 Sildenafil (Viagra)
 4H half life
 1H before planned sexual activity
 S/E: headache, flushing, dyspepsia, nasal congestion, visual
disturbances
 Vardenafil (Levitra)
 1H before planned sexual activity
 4-6H half life
 Tadalafil (Cialis)
 30 min before sexual activity
 17H half life
 Less side effects
 Does not CREATE erections, only maintains
vasocongestion
Sexual stimulation Nitric oxide
activates

Erection Guanylyl cyclase

produce

Promotes smooth muscle relaxation cGMP PDE5

Surgery

 Vestibulectomy
 Close to 100% cure rates
 Excision of the hymen and sensitive areas of the
vestibules
GENDER IDENTITY DISORDER

 Formerly known as transsexualism

 Individual feels that they are of the opposite
sex despite normal genitals and these
feelings usually present since childhood
 May seek out surgery to alter body
 Individuals with GID may be sexually
attracted to same or opposite sex individuals
ETIOLOGY OF GENDER DISORDER

 Genetic factor
 Twin studies indicate some symptoms moderately
heritable
 Neurobiological Factors
 Exposure to high level of sex hormone in utero
 Social and psychological factors
 Reinforcement of cross gender behaviour
TREATMENT

 Sex reassignment surgery

 Alter person’s sexual anatomy to match internal
identity

 Behavioral treatment to alter gender identity

 Shaping of more masculine behaviours
 May only be effective for individuals who wants
treatment for GID
PARAPHILIAS
 Paraphilias involve the preferential use of unusual objects of
sexual desire or engagement in unusual sexual activity. To fit
DSM-IV-TR criteria, the behavior must continue over a period of
at least 6 months, and cause impairment in occupational or social
functioning.
 1. Paraphilias occur almost exclusively in men.
 2. Pharmacologic treatment includes antiandrogens and female
sex hormones for para­philias that are characterized by
hypersexuality.
Fetishism

 Reliance on an inanimate object for sexual

arousal
 Eg: shoes, stockings, underwear, rubber garments
 Occurs most offen in men

 Attraction to object irresistable and

involuntary
TRANSVESTIC FETISHISM

 Transvestism
 Recurrent intense sexual arousal from cross
dressing
 No desire to be of the opposite sex
PEDOPHILIA

 Sexually arousing urges, fantasies or

behaviours involving sexual contact with
prepubescent child

 Victims usually known to pedophile

 Mostly does not involve violence other than

the sexual activity
Voyeurism

 Sexually arousing fantasies, urges or

behaviors involving observing other who are
unclothed or engaging in sexual activity
 Almost always men
 Seldom result in physical contact with victim
 Victim unaware that they are being watched
EXHIBITIONISM

 Intense desire to obtain sexual gratification

by exposing one’s genitals to unwilling
stranger
 Seldom results in physical contact with victim
 Usually involve desire to shock or alarm victim
Frotteurism

 Sexually oriented touching of a

nonconsenting person
 Rubs his genitals against a woman body of fondles
her breast or genitals
 Usually occur in crowded subway or other public
place
SEXUAL SADISM AND MASOCHISM

 Sadism
 Intense and recurrent desire to obtain or increase
sexual gratification by inflicting pain or
psychological suffering on another person
 Masochism
 Intense and recurrent desire to obtain or increase
sexual gratification through receiving pain or
humiliation
Treatment

 External control
 Reduction of sexual drives
(depression/anxiety)
 Cognitive Behaviour Therapy
 Dynamic Psychotherapy
 SEXUALITY AND ILLNESS

Heart disease and myocardial infarction (MI)

 Men who have a history of MI often have erectile dysfunction. Both
men and women who have a history of MI may have decreased
libido because of side effects of cardiac medica­tions and fear that
sexual activity will cause another heart attack.
 Generally, if exercise that raises the heart rate to 110-130 beats per
minute (e.g., exertion equal to climbing two flights of stairs) can be
tolerated without severe shortness of breath or chest paro, sexual
activity can be resumed after a heart attack.
 Sexual positions that produce the least exertion in the patient (e.g.,
the partner in the superior position) are the safest after MI.
 SEXUALITY AND ILLNESS

Diabetes
 One quarter to one half of all diabetic men (more commonly older patients)
have erectile dysfunction. Orgasm and ejaculation are less likely to be
affected.
 The major causes of erectile dysfunction in men with diabetes are vascular
changes and diabetic neuropathy caused by damage to blond vessels and
nerve tissue in the penis as a result of hyperglycemia.
a. Erectile problems generally occur several years after diabetes is diagnosed
but may be the first symptom of the disease.
b. Poor metabolic control of diabetes is related to increased incidence of
sexual problems.
c. Sildenafil citrate and related agents often are effective in diabetes-related
erectile disorders.
d. Although physiologic causes are most important, psychological factors
also may influence erectile problems associated with diabetes.
 SEXUALITY AND ILLNESS

Spinal cord injury

 in men cause erectile and orgasmic dysfunction,
retrograde ejaculation (into the bladder), reduced
testosterone levels, and decreased fertility.
 in women cause problems with vaginal lubrication,
pelvic vasocongestion, and orgasm. Fertility is not
usually adversely affected.
 SEXUALITY AND AGEING
Physical changes - alterations in sexual functioning normally occur
with the aging process.
 1. In men, these changes include slower erection, diminished
intensity of ejaculation, longer refractory period, and need for
more direct stimulation.
 2. In women, these changes include vaginal thinning, shortening
of vaginal length, and vaginal dryness.
 3. Hormone replacement therapy, which can reverse these
vaginal changes, is used less frequently now than in the past.
However, local application to the vagina of moisturizing agents
can be helpful.
 SEXUALITY AND AGEING
Sexual interest and activity
 1. In spite of physical changes, societal attitudes, and
loss of the sexual partner due to illness or death,
sexual interest usually does not change significantly
with increasing age.
 2. Continued sexual activity is associated with good
health. Prolonged abstinence from sex leads to
faster physical atrophy of the genital organs in old
age.
 SEXUALITY AND MEDIACATION
A. Prescription drugs affect libido, erection, orgasm, ejaculation, and
other sexual functions, often as a result of their effects on
neurotransmitter systems .
B. Prescription drugs that lead to decreased sexual function include
 1. Antihypertensives, particularly a-adrenergic agonists (e.g.,
methyldopa) and (3-adrenergic blockers (e.g., propranolol); the
fewest sexual problems are found with use of angiotensin­converting
enzyme (ACE) inhibitors (e.g., captopril).
 2. Antidepressants, particularly SSRIs, since serotonin may depress
sexuality and delay orgasm.
 3. Antipsychotics, particularly dopamine-2 receptor blockers
a. Dopamine may enhance sexuality; its blockade may decrease
sexual functioning.
b. Prolactin levels increase as a result of dopamine blockade; this
may in turn depress sexuality.
 SEXUALITY AND MEDIACATION
C. Drugs of abuse
 1. Alcohol and marijuana increase sexuality in the short term
by decreasing psychological inhibitions.
 a. With long-term use, alcohol may cause liver dysfunction,
resulting in increased estrogen availability and sexual
dysfunction in men.
 b. Chronic use of marijuana may reduce testosterone levels
in men and pituitary gonadotropin levels in women.
 2. Amphetamines and cocaine increase sexuality by
stimulating dopaminergic systems.
 3. Heroin and, to a lesser extent, methadone are associated
with suppressed libido, retarded ejaculation, and failure to
ejaculate.
THANK YOU