SEXUALITY AND ITS DISORDERS

Akin Ojagbemi
MB;BS, PhD, FMCPsych, FWACP
 What is sexuality?

 It reflects the developmental experiences with sex

throughout the sexual cycle

 Includes the perception of being man or woman

 It encompasses the thoughts, feelings, and behaviour

connected with sexual gratification, and
reproduction
 Normal sexuality

 Depends on four interrelated psychosexual factors:

1. Sexual identity: The biological sexual characteristics (e.g,
chromosomes, genitalia, hormones, secondary sexual characteristics)

2. Gender identity: An individual’s sense of her/his sex

This conviction is reached by age of 2-3 years
It results from a series of environmental clues

3. Sexual orientation: The object of a person’s sexual impulses

Heterosexual, homosexual or bi-sexual

4. Sexual behaviour: All the activities engaged in to express and

gratify sexual needs
May include desire, fantasies, pursuit of partner e.t.c.
 The sexual response cycle

 This is the sequence of normal physiological responses to

sexual stimulation:
I. Desire: The conscious desire to have sexual activities
It is psychological, and depends on motivation and personality

II. Excitement: Consists of a subjective sense of pleasure and an

objective sense of excitement
It is psychological and/or physiological

III. Orgasm: This is a physiological peaking of sexual excitements

IV. Resolution: This brings the body back to a resting state

Longer in males, and with age
Resolution through orgasm is associated with a subjective sense of
wellbeing
 Abnormal sexuality

 This may be viewed as a sexual behaviour with any of the

following characteristics:
1. Destructive to oneself and others
2. Cannot be directed towards a partner
3. Excludes stimulation of the primary sexual organs
4. Associated with guilt and anxiety
5. A person is unable participate in a sexual relationship as she/he would
wish to

 Abnormal sexuality may take the form of sexual dysfunction or

deviation

 Sexual dysfunction:
In general: The repeated impairment of normal sexual interest and/ or
performance
In women: repeated unsatisfactory quality of sexual experience
 Classification of sexual dysfunctions
Diagnostic and statistical manual (DSM IV)
 Sexual dysfunction:
1. Sexual desire disorders
 Hypo-active sexual desire disorder
 Sexual aversion disorder
2. Sexual arousal disorder
 Female sexual arousal disorder
 Male erectile disorder
3. Orgasmic disorders
 Male and female orgasmic disorders
4. Premature ejaculation
5. Sexual pain disorders
 Dyspareunia
 Vaginismus
6. Sexual dysfunction due to general medical
conditions
 The Paraphylias
 Transvestic fetishism
 Gender Identity Disorders:
1. In children
2. In adolescent and adults
International classification of diseases (ICD 10)
 Non-organic sexual
dysfunction
1. Lack or loss of desire
 Sexual aversion and lack of
enjoyment
2. Sexual arousal disorder
 Failure of genital response
3. Orgasmic dysfunction
4. Non-organic dyspareunia
5. Non-organic vaginismus
6. Excessive sexual drive
 Disorders of sexual preference
 Fetishistic transvestism
Note: gender identity disorder is
coded as a personality disorder
in ICD 10
 SEXUAL DESIRE DISORDERS

 Hypoactive sexual desire:

Deficiency or lack of sexual fantasies and desire for sexual
activity
Starts at puberty, and may remain lifelong

• Risk factors;
Ego defence against unconscious fears about sex
Chronic stress
Anxiety and depression
Prolonged abstinence
Hostility towards partner
Deteriorating relationship with the partner
Low serum testosterone
Central dopamine blockade
Sexual aversion disorder:
A Persistent or recurrent aversion to, and avoidance
of, all or almost all genital sexual contact with a
partner

• Risk factors;
Traumatic sexual assault (e.g, rape, abuse)
Repeated painful experiences with coitus
Early developmental conflicts
Perceived psychological assault from a partner
Deteriorating relationship with the partner
 SEXUAL AROUSAL DISORDERS

 Female sexual arousal disorder:

Persistent/recurrent, partial/complete, failure to attain
or maintain the lubrication-swelling response of sexual
excitement until the completion of the sexual act
Commoner in post-menopausal women
Frequently co-exist with orgasmic problems,
dyspareunia, or lack of desire

• Other risk factors;

Psychological (e.g, rejection of the partner)
Hormonal changes (e.g, testoterone, estrogen)
Medications (Anti-histamines and anti-cholinergics)
Male erectile disorders (impotence):
A persistent/recurrent inability to attain/maintain, until completion of the sexual activity, an
adequate erection
Successive episodes are reinforcing (performance anxiety)
Normal erection is a neurovascular phenomenon where vascular changes are caused by the
parasympathetic autonomic nervous system (S2,3,4). This is influenced by a combination of
tactile, central limbic and cognitive mechanisms

• Risk factors;
Psychological conflicts (e.g anxiety, morality)
Feelings of inadequacy
Difficulties between partners

• Specific treatment;
1. Biological
a. Drugs:(Phosphodiesterase type 5 inhibitors, Sublingual apormorphine, intracavernousal
papaverine)
b. Vascular surgery
c. Prosthesis
2. Psychological treatment
a. Cognitive behaviour therapy
b. Sensate focused therapy
c. Psychodynamic psychotherapy
 ORGASMIC DISORDERS

 Female orgasmic disorder (anorgasmia):

The recurrent or persistent inhibition of the female
orgasm. Manifested by the absence or delay in orgasm
after a normal sexual excitement phase judged to be of
adequate intensity and duration
It excludes women who can achieve orgasm with non-
coital stimulation
Associated factors are mostly psychological(e.g, fears
of impregnation, damage to the vagina, hostility
towards men, e.t.c)

• Specific treatment; Masturbation training

Male orgasmic disorder:
Persistent/recurrent delay in/absence of orgasm, after a
normal sexual excitement phase judged to be adequate in
duration and intensity
Note: This is different from retrograde ejaculation

• Risk factors;
Obsessive compulsive disorder
Genito-urinary surgery (e.g, prostactectomy)
Neurological disorders (e.g, Parkinson’s disease)
Anti-hypertensives (e.g, methyl-dopa)
Phenothiazines (e.g, chlorpromazine)
Anti-depressants
Hyperglycaemia
Excessive alcohol intake
Premature ejaculation:
Persistent or recurrent ejaculation with minimal sexual
stimulation, on or shortly after penetration, and before the
person wishes it

• Risk factors;
Higher level of education
Psychological (anxiety, high expectation, e.t.c)
Conditioning (e.g, Need to hurry up!)
A stressful marriage

• Specific treatment;
1. Pause technique
2. Squeeze technique
3. Use of Fluoxetine
SEXUAL PAIN DISORDERS
 Dyspareunia:
Recurrent or persistent pain during intercourse in either
a man or woman
Note: Rule/out vaginismus or a medical cause for the pain

• Risk factors;
Women
History of vaginal surgeries
History of rape or childhood sexual abuse
Men
Genito-urinary diseases (e.g, prostatitis, gonorrhoea)
Vaso-congestion without ejaculation
Post-ejaculatory pain (psychological, anti-depressants )
Vaginismus:
Recurrent or persistent constriction of the outer one-
third of the vagina that prevent penile insertion and
intercourse

• Risk factors;
Highly educated women
Women of higher socio-economic class
Sexual trauma (e.g, rape or other sexual abuses)
Non-sexual painful trauma (e.g, accident, surgery)
Psycho-sexual conflicts about the penis or intercourse
(e.g, penis perceived as dangerous?)
Strict religious up-bringing
 Sexual dysfunction due to general medical conditions

 Sexual dysfunction that results in marked distress and

interpersonal difficulties, where there is evidence of a general
medical condition judged to be causally related to the dysfunction

 The following conditions are associated with impotence:

Diabetes,
Parkinson’s disease,
Epilepsy,
Peripheral neuropathy,
Substance dependence,
Prostactectomy,
Radiation therapy,
Pelvic fracture
 General treatment for sexual dysfunction
 Dual sex therapy: Views the problem in one partner as the problem of both
Involves the use of Sensate focus (sex) exercises and home work
The goal of treatment is to improve communication on sexual matters and to
reduce performance anxiety

 Other Psychological Therapies:

Hypnotherapy for anxiety symptoms
Behavioural therapy using learning theories
Group therapy
Integrated sex therapy; sex therapy + psychotherapies

• Biological treatments:
Drugs-(e.g, sidenafil, hormones)
vacuum pumps
Male prostheses,
Female surgical procedures
 Disorders of sexual deviation (Paraphilias)
 These disorders are characterised by pathognomonic sexually
arousing fantasies, urges, or other behaviour involving the
following:
1. Non-human objects
2. The suffering or humiliation of Self or partner
3. Children or non-consenting adults

 Impairment in functioning and significant emotional distress

should be present to make the diagnosis
Note: The diagnoses may be tenable if the behaviour obligatory,
obsessive, recurrent or persistent for at least 6 months.

 The paraphilias occur almost exclusively in men

 Fetishism: is the use of non-living objects, usually
clothes, which the patient may hold, rub, smell, for sexual
arousal
The fetish object is usually linked to someone
usually begins in adolescence

 Transvetic fetishism: cross dressing in a heterosexual

person, associated with sexual arousal, and wish to
discontinue after reaching orgasm.
Note: transexual transvetism is not motivated by sexual
pleasures

 Exhibitionism: Persistent exposure of one’s genitals in

public in order to derive sexual excitement
This is usually followed by masturbation.
 Voyeurism (Scopophilia): Persistent derivation of sexual
arousal through observing un-suspecting persons unclothed
or involved in sex.
The first act usually occurs in childhood, and most patients
are arrested for loitering

 Peadophilia: Behaviours that include sexual activities with

children
The victim should be less than 13 years, while perpetrator
should be up to 16 years
Most victims are boys

 Sexual sadism: sexual arousal from inflicting physical or

psychological suffering
 Frotteurism: Sexual arousal by touching or rubbing against
an unsuspecting person