Sexuality

1
Sexuality

• Jonathan J. Mayer, MD
• University of Tennessee Health Science Center
• Department of Obstetrics and Gynecology
• November 11, 2004

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Introduction

• The OB/Gyn should understand the concepts of
  sexual development and identity, as well as the
  psychology of sexual relations.
• The practitioner also should understand the ways
  in which a patients sexuality may be altered by
  physical or psychologic conditions.
• The OB/Gyn should be familiar and comfortable
  with the terms used in sexual counseling and
  should understand the range of disorders of
  sexual function.

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Introduction

• Sexual satisfaction is one of the more important
  human experiences, yet it has been estimated that
  as many as 50 of all married couples (who knows
  about the unmarried ones..), 60 of women, and
  40 of men experience some sexual dissatisfaction
  or dysfunction at some time.
• Although there is a strong physical basis for
  sexual function, it is impossible to separate
  sexual response from the many emotional and other
  contributing factors that may influence a
  relationship.

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Introduction

• Any gynecologic or medical disorder that causes
  pain, that alters physical appearance in an
  undesirable manner, or that alters a womans view
  of herself and/or her sexuality may cause or
  contribute to sexual dysfunction.
• Gynecologists appropriately treat a number of the
  simpler sexual issues when they demonstrate a
  nonjudgmental, empathetic attitude, and a
  willingness to truly listen.

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CREOG Objectives

• Describe the stages of the normal sexual
  response
• Desire
• Arousal
• Orgasm
• Resolution
• Refractory Period
• Sex will never be the same again..

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CREOG Objectives

• Describe the principal disorders of sexual
  function
• Loss of desire
• Loss of arousal
• Anorgasmia
• Vaginismus
• Dyspareunia

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CREOG Objectives

• Elicit a complete sexual history
• Perform a focused physical examination to
  identify a specific disorder of sexual
  dysfunction or determine the cause of sexual
  dysfunction

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CREOG Objectives

• Describe possible interventions for patients with
  disorders of sexual function
• Counseling
• Medical Therapy
• Surgery

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CREOG Objectives

• Describe the appropriate long-term follow-up for
  patients with disorders of sexual function

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Stages of the Normal Sexual Response

• Masters and Johnson (1966) published their now
  famous book, Human Sexual Response
• Basis for our current understanding of the female
  sexual response
• Based on observations of the sexual cycle of over
  700 women
• Categorized female sexual response into four
  stages
• Excitement
• Plateau
• Orgasm
• Resolution

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Stages of the Normal Sexual Response

• Desire
• Wanting it..

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Stages of the Normal Sexual Response

• Arousal/Excitement/Seduction
• Initiated by a number of internal or external
  stimuli
• Physiologically
• Deep breathing
• Increased heart rate and BP
• Total body feeling of warmth
• Increase in sexual tension
• Generalized vasocongestion (..the sex flush..)
• Breast engorgement/Nipple erection
• Maculopapular, erythematous rash on the breasts,
  chest, tummy
• Engorgement of the labia majora
• Clitoral erection
• Vaginal sweat
• Uterine tenting
• Response caused by parasympathetic stimulation
• Anti-cholinergic drugs can interfere with a full
  response

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Stages of the Normal Sexual Response

• Plateau
• Culmination of the excitement phase
• Marked vasocongestion throughout the body
• Formation of the orgasmic platform
• Decrease in diameter of vagina by as much as 50
• Clitoral retraction against the pubic symphysis
• Vaginal lengthening
• Dilation of upper two-thirds of vagina
• Further uterine tenting

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Stages of the Normal Sexual Response

• Orgasm
• Sexual tension that has been built up in the
  entire body is released
• Physiologically
• Generalized myotonic contractions
• Contractions of perivaginal muscles and anal
  sphincter
• Uterine contractions (great way to induce
  labor)
• Prolonged excitement phase leads to more
  pronounced orgasmic activity
• Under control of sympathetic nervous system
• Antihypertensive drugs may affect orgasmic
  response
• Women (unlike men) can have multiple orgasms with
  no refractory period required

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Stages of the Normal Sexual Response

• Resolution
• A return of the womans state to the
  pre-excitement level
• A general feeling of personal satisfaction and
  well-being
• Refractory Period
• No such thing in women..

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Principal Disorders of Sexual Function

• Loss of Desire/Arousal
• Not wanting it..
• Most common sexual dysfunction
• Basis very individualized
• Treatment by counseling
• Result vary..
• All disorders of desire are complex situations
  which require considerable time and expertise to
  diagnose and treat.
• Multiple team members with the OB/Gyn at the
  center

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Principal Disorders of Sexual Function

• Loss of Desire/Arousal
• 2 specific disorders
• Hypoactive Sexual Desire Disorder (HSDD)
• Usually presents as a troubling relationship
  issue
• Sexual Aversion Disorder (SAD)
• Powerful adverse somatic response to sexual
  activity

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Principal Disorders of Sexual Function

• Anorgasmia/Orgasmic Dysfunction
• Background
• 10-15 of women have never experienced an orgasm
• Not all women can achieve orgasm via intercourse
  despite achieving through other means
• Need to discern extent of problem and place into
  proper context
• Treat by combination of psych counseling and
  physical techniques
• May be done by OB/Gyn
• Techniques need to involve both self and partner

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Principal Disorders of Sexual Function

• Vaginismus
• Definition
• Condition secondary to involuntary spasm of
  vaginal introital and levator ani muscles
• Penetration is either painful or impossible
• Complain of pain and fear of pain
• Coitus/Pelvic exam
• Use of tampons or vaginal medications
• Basis
• Early sexual abuse
• Aversion to sexuality in general
• Rape
• Painful episiotomy experiences
• May also occur after an injury or infection that
  led to pain with attempted intercourse

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Principal Disorders of Sexual Function

• Vaginismus
• Therapy
• Identify underlying cause
• Effect a relearning process with partner involved
• Treat actual vaginal spasm
• Patient self-dilation
• Partner participation
• Usually short course
• Results usually good

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Principal Disorders of Sexual Function

• Dyspareunia
• Frequently has an organic basis
• Careful history required
• When it occurs
• Insertion
• Thrusting in mid-vagina
• Deep penetration of the vaginal vault
• History leads to treatment
• Possible causes
• Poor lubrication
• Urethritis/Cystitis/Trigonitis
• Poorly healed vaginal lacerations or episiotomy
• PID
• Endometriosis

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Principal Disorders of Sexual Function

• Dyspareunia
• Treat the organic cause
• Dont forget to consider something as simple as
  sexual positioning..
• When no organic cause is found
• Treat with techniques similar to those used to
  evaluate and manage vaginismus

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Sexual History

• Ask generally about each of the following
• Sexual Activity
• Heterosexual/Lesbian/Bisexual
• Toys used
• Satisfaction (self and within relationships)
• Intercourse
• Comfortable
• Enjoyable
• Orgasm
• Yes or No
• Explore any issues with specific questioning to
  outline extent of problem and the basis for it..

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Physical Exam

• Focused exam based on history
• Particularly important in evaluating vaginismus
  and dypareunia
• Harder to do for desire/arousal/orgasmic
  dysfunction
• Use to rule out organic etiologies

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Possible Interventions

• Counseling
• May be done by OB/Gyn if trained appropriately
• Often involves debunking commonly held sexual
  myths and misinformation
• Often done by Sex Therapists
• Make sure referrals are only to well trained and
  degreed (MD/PhD/Social Worker) individuals
• Success usually requires involving the patients
  partner
• Relationship issues

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Possible Interventions

• Medical Therapy
• Based on organic cause
• Surgical Therapy
• Based on organic cause

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The PLISSIT Model

• Permission
• Because of confused attitudes and feelings
  associated with sexuality, patients need
  permission to think about and work on sexual
  issues
• Limited Information
• Provision of information to combat fear and
  concern based on a lack of knowledge
• Specific Suggestions
• Specific to the patients issue
• Intensive Therapy
• Usually beyond the scope of the OB/Gyn

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Follow-up

• Short-term
• Frequent (weekly?) visits during early therapy
• Space out visits as patient progresses
• Always be available in case of crisis or relapse
• Long-term
• Discuss issues at every visit
• Open communication
• Always be available

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References

• Comprehensive Gynecology
• Stenchever/Droegemueller/Herbst/Mishell
• Fourth Edition
• Obstetrics and Gynecology/Principles for Practice
• Ling/Duff
• 2001