Assessment and Management of Sexual Dysfunction

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• Assessment and Management of Sexual Dysfunction
• Professor Dinesh Bhugra
• Professor of Mental Health and Cultural
  Psychiatry
• Institute of Psychiatry
• Kings College London

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Why do sexual problems arise?

• 1. Misunderstanding of, lack of information
  about, sex
• 2. Bad feelings about sex
• - Fear of pain, pregnancy, being caught,
  failure, losing control, partner losing control
• - Guilt
• Problems in the relationship
• - Anger, jealousy, resentfulness
• - Feelings of insecurity
• Unsuitable circumstances
• - Lack of privacy, comfort
• - Feeling too tired, hurried
• Alcohol / Drugs
• Poor health

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Classification
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ICD-10 Classification
625.80 hypoactive sexual des. 608.89
hypoactive 607.84 Male erection 625.00
dyspareunia 608.89 dyspareunia 625.80
Other female sexual dysfunction 608.89
Other sexual dysfunction Due to
co-morbid medical condition
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DSM-IV
302.85 Gender Identity Disorder in adolescents
or adults Specify if sexually attracted to /
/ both / neither 302.6 Gender Identity
Disorder in childhood 302.6 Gender Identity
Disorder NOS
ICD 10 F64.0 Transsexualism F64.2 Gender
Identity Disorder of childhood F64.1 Dual-role
Transvestism F64.8 Gender Identity Disorders
GENDER - IDENTITY
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Classifications Of Sexual Dysfunctions
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DSM-IV and ICD-10 Criteria For Loss of Sexual
Desire

• DSM-IV 302.71 Hypoactive sexual desire disorder
• Persistently or recurrently deficient (or absent)
  sexual fantasies and desire for sexual activity.
  The judgement of deficiency or absence is made by
  the clinician, taking into account factors that
  affect functioning, such as age and the context
  of the persons life.
• B. The disturbance causes marked distress or
  interpersonal difficulty.
• C. The sexual dysfunction is not better accounted
  for by another Axis I disorder (except another
  sexual dysfunction) and is not due exclusively to
  the direct physiological effects of a substance
  (e.g. a drug of abuse, a medication) or a general
  medical condition.
• Specify type Lifelong type
• Acquired type
• Specify type Generalised type
• Situational type
• Specify type Due to psychological factors
• Due to combined factors
• ICD-10 F52.0 Lack or loss of sexual desire
• Loss of sexual desire is the principal problem
  and is not secondary to other sexual
  difficulties, such as erectile failure or
  dyspareunia. Lack of sexual desire does not
  preclude sexual enjoyment or arousal, but makes
  the initiation of sexual activity less likely.
  Includes frigidity and hypoactive sexual desire
  disorder

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Prevalence
Slag et al (1983) MOPD N1180 34 complained
of erectile difficulties Of these 25
medication effects 19 Pry or secy
hypogonadism 9 Diabetes 14
Psychogenic Frank et al (1978) happily
married Inability to achieve erection
7 Difficulties in maintaining 9 Spector and
Carey (1990) 4-9 erectile disorders In clinics
35-45 in 1970s 53-56 in 1980s
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History Taking
Age of onset of puberty and reactions Voice
breaking, shaving menarche secy. sexual
character) Masturbation Age, fantasies,
anxieties Sexual Orientation Homosexual /
heterosexual fantasies, inclinations,
experiences, deviations Current Sexual
Practice Marital, extra marital Contraception Sex
ual satisfaction Marital H/O Previous
engagements, associated circumstances Courtship
Age at marriage(s) Age, occupation, health of
partner Relationship Marriage forced by
pregnancy Fidelity Dates of divorce /
separation Partnership
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Principles 1. Assessment 2. Manage anxiety 3.
Education 4. Physical 5. Psychological   Assessmen
t Thorough Expectations Attitudes Problem exact
extent Why now ?
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Suitability Nature General relationship Motivat
ion Psych dis Physical illness Pregnancy  Aims
of assessment 1. To identify the problem and aim
of Rx 2. To identify the causes 3.
Interaction Note-taking Confidentiality Intervi
ew Nature of the questions Language Open-ended
Experience Specific occasion Conjoint
assessment Cultural problems
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Main Headings of History-Taking
1.Presenting problems (i) Sexual problem (ii)
Associated factors 2. Relationship (i)
Quality (ii) Positive factors (iii) Negative
factors 3. Personal History
(i) Onset of puberty (ii) Extent of sexual
education (iii) Sex knowledge and sources (iv)
Early family environment (v) Masturbation
(vi) Dating, patterns of petting (vii)
Intercourse a. First experience b. Present
pattern and practice c. Frequency then and
now d. Fantasies 4. Expectations of treatment
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Sex History
The headings are designed as a guide, not as a
question and answer format. Please add any other
facts of relevance in the spaces
provided.   Couple Informant
Date Interviewer  PRESENT PROBLEM Sexual
Problems description duration date of
onset severity last successful experience anything
makes it better? precipitants (original or
continuing) frequency of problem attempts to
treat it so far present with other
partners? present in different situations?
Associated Factors drugs (prescribed or
not) alcohol anxiety (work, family,
performance) other psychiatric
disorders physical illness
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Sex History Contd
Please use this space for a general description
of problem
Relationship Quality   problems in relationships
(e.g., tension, hostility, arguments) lack of
communication threat of separation over-protecti
on invalidism lack of warmth dominance jealous
y irresponsibility, social factors attraction
factors positive strengths other factors
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Sex History Contd
Menstruation Age? Was it explained in
advance? How and by whom? Feelings after
menstruation began? Any problems? (then and
now) Last menstrual period
Family Environment Was sex discussed at
home? Religious or strict family? Easy-going? Did
parents show physical affection to each other or
you? Parents attitudes to sex Do you remember
any upsetting experience to do with sex in
childhood or later? (e.g. homosexual assault,
paedophilia) Parents sexual relationship? Family
atmosphere (relationship, alcohol, violence,
criminal, psychiatric, bereavement, disabilities,
deprivation)
Sex Education and Knowledge Age when learned the
facts of life? Who told you? Reaction? Quality of
present knowledge?
Erection and ejaculation Age? Wet dreams? Morning
erections (then and now)
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Sex History Contd
Intercourse Age? How did you respond sexually?
(problems) Where did first SI occur and when? How
did you feel about sexual intercourse? Did your
partner have any problems? Sexual Relationships
(including marriages and cohabitations) Number?
(Same and opposite sex) Duration and reason for
separation? How was sex? How was the relationship?
Masturbation Age? Frequency? (then and now) How
did you feel about doing this? Were you ever
caught? Technique aids.
Dating  Age? What kind of petting? (e.g. touching
of genitals?) Where and in what
circumstances? How did you respond sexually? How
did you feel about petting?
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Sex History Contd
Present relationship Age of first
meeting? Married, cohabiting, single? If married,
year of marriage When was first sexual
intercourse? Frequency of sexual intercourse,
initially and at present. What is your ideal
frequency? Did you enjoy sexual intercourse when
you first met? Do you enjoy sexual intercourse
now? How do you respond sexually? (expand
degree of arousal, orgasmic response, pain during
penetration, erectile or ejaculatory
difficulties) Who takes the initiative? Do you
feel tense and anxious during sex? Have you had
affairs since you met your partner? Were they
sexually satisfying? Did you tell your partner?
Current Practices and Preferences What specific
sexual activities do you find enjoyable? Do you
ever feel inhibited, embarrassed or guilty about
any aspect of sex? Do you enjoy foreplay?
(including genital stimulation) What position do
you like? Do you enjoy oral sex? (him her) (she
him) What time of day and where? (lighting,
sound) What do you like to wear? (e.g. nude,
nightwear, other)
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Sex History Contd
Fantasy Do you ever have sexual fantasies during
masturbation, foreplay or sexual intercourse?
Other times? Describe preferred fantasy.
General Factors Difficulties in pregnancy and
delivery Expectations of treatment Who initiated
referral? Why have they come now?
Eroticism Which of your senses or situations turn
you on? (touch, sight, smell, taste, sound,
stories, films, pictures, dancing, touching
partner, or materials) What turns you off about
your partner?
Therapist Formulation
Contraception Present method? Any problems
Obstetric History Terminations of pregnancy or
miscarriages, stillbirths Number of
children. Number of children wanted?
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Sex History Contd

Interviewers comments on this questionnaire
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Principles of Treatment

• Education
• Psychological
• General Relaxation
• SF I
• SF II
• 3. Physical
• Partners Together
• Communication
• Educate
• Tasks

Specific Male Erectile Dysfunction Testosterone
s Drug Rx Stop-Start Female Superior Desensiti
zation Positive conditioning PME Squeeze and
Stop-Start
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Origins of Psychological Problems

• Misunderstanding and ignorance
• Unsuitable circumstances
• Bad feelings about sex,
• about oneself,
• about ones partner
• Communication
• Patterns of marriage / marital discord

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Causes
MMT
EDUCATION
PERMISSION GIVING
TEACH COMMUNICATION
SEXUAL FAILURE
Fear of failure Unrealistic
Redefinition of success expectations
Removal of pressure
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Physical Examination

• Recent history of ill-health, presence of
  physical symptoms
• Pain or discomfort during sexual activity
• Recent onset of loss of desire without any
  apparent cause
• Inability to produce normal erection whilst awake
  (under any circumstances)
• Males aged gt50
• Females in peri- or post-menopausal age groups
• Past H/O abnormal puberty or endocrine disorder
• Patient believes a physical cause likely

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HUMANS Sexual activity is far in excess of that
required for optimum fertility
GENDER ENDOCRINOLOGY
BIOLOGY
PSYCHOLOGY
SOCIAL
SEXUAL DEVELOPMENT (after Bancroft)
PRE NATAL
Gender Identity
Dyadic Relationships
Sexual Resp
CHILDHOOD
ADOLESCENCE
ADULTHOOD
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• THREE STRANDS
• Sexual differentiation into male or female
  BIOLOGY
• Sexual responsiveness
• Capacity for close dyadic relationships
• SIX BASIC STAGES
• Prenatal
• Childhood
• Adolescence
• Marriage Establishment of stable sexual
  relationship
• Early parenthood
• Late parenthood
• Mid-life

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ATTITUDES FEARS EXPECTATIONS

COGNITION
-
F
-

LIMBIC SYSTEM
AWARNESS OF RESPONSSE

A

E
ORGASM
SPINAL CENTRES
B
C

PERIPHERAL AROUSAL
-

D
GENITAL RESPONSE
-
Tactile Stimuli
BANCROFTS CYCLE (PSYCHOSOMATIC CIRCLE)
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Assessment Separate assessors
Self-rating scales Outcome Measures
Global Functional Sexual
Relational Questions about Privacy
Questions about Confidentiality Follow-up
Drop-outs Before assessment Before
randomisation Before completion Volunteers
for sex research Resources
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Particular Difficulties Difficulties in
defining - Rx purity - Rx distinctness
Control Group vs Placebo Large samples
therefore small sizes of treatment effect
Measures of outcome are soft and choice of
measures is critical - Objective -
Self-report - Standardised - Specific measures
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Focus on Precipitating factors Predisposing
factors Maintaining factors Understand Problem
in global dimension Sensitive
questioning Flexible planning of treatment

• Special attention to female role
• Special attention to childbearing
• Role of other members of family
• Role of previous knowledge

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Male Erectile Disorder
Persistent or recurrent partial or complete
failure in a male to attain or maintain erection
until completion of sex play, - or -
  Persistent or recurrent lack of a subjective
sense of sexual excitement and pleasure in a male
during sexual activity.   Primary   Secondary  
Psychogenic vs. Organic
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Additional Factors
Sexual orientation Ageing Infertility Fantasy Para
philias Religion Education Social
status Migratory status C.S.A.
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Psychological Approaches 
Masters and Johnson
Behaviour T. Relaxation Anxiety
Management CBT Refrain from S.I.
Intimate behaviour encouraged Graded sexual
exercises - Non-genital S.F. - Genital S.F. -
Enhanced communication Verbal
Non-Verbal - Specific techniques PME Squeeze
technique Retarded ejaculation
Over-stimulation Cognitive elements included
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Physical Management
A.     ORAL MEDICATION Yohimbine
2 adrenegic receptor blocker Idazoxan
Sildanafil Tiladanafil Ambiguous
Results B.     INTRACAVERNOSAL INJECTIONS 
Phenoxybenzamine hydrochloride Papaverine
hydrochloride Phentolamine mesylate
Prostaglandin E   C. ARTIFICIAL
DEVICES 1917 Olto Lederer Vacuum Pump
Fillin go fthe corpora due to suction and statis
passive Constriction device at the base
Hand Pump
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Prostaglandin E 5-10 mcgms to start 20-40
mcgms maximum May produce priapism but less
likely than Papaverine Investigate C.V.S. Live
r function Substance misuse Allergic
reactions H/o sexual offending Side
Effects Priapism Painful nodules in the
penis Fibrotic nodules Liver damage Pain Infec
tion Bruising
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Papaverine alone or in combination with
Phentolamine
Most likely responders are Mild cases of
arteriogenic aetiology All cases of neurogenic
aetiology Mild cases of abnormal leakage
Unsuccessful surgical procedures Dosage
Start with 8-15mgm producing erection for 10-15
minutes Gradual increase First trial
Papaverine 15mgm, add Phentolamine 0.5mg,
Then 0.5mg Phentolamine 30mg Papaverine,
Max 2mg Phentolamine 60mg Papaverine.
Administration Use insulin syringe, gauge 26
or 27 needle If Phentolamine first, patient
should be lying down Not more than twice
weekly, two-day interval If no erection,
investigate venous leak Erection appears 10-20
minutes and may last 30minutes or so.
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Correctaid Blakoc Supensory Energising
Ring Side effects Haematoma Pain Ecchymois
Painful ejaculation
Ebonite metal plates
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Surgical Procedures
Revascularisation Epigastric artery with corpora
Sephaneous vein bypass  Prosthesis Inflatable
penile implant Semi rigid prosthesis Perineal
approach Corporeal bodies Flexi-rod 0.9- 1.2cm
diameter 7-13cm long Semi rigid 12-22cm
long 0.9mm, 1.12mm 1.3mm diameter
Jonas Subcoronal, midshaft, penoscrotal Suprapub
ic or perineal approaches 9.5mm, 11.0mm and
1.3mm diameter 1624cm long Inflatable
prosthesis Inflate/deflate pumps in one
mechanism Age Co-existing medical
problems Patient preference Risk of
complications
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  Behaviour Skills Genital Sex Disorders of
desire (Irvine 1990) Medicalization of sexual
boredom or indifference What about new
disorders?   Sexual addiction Dissatisfaction
with body image   Culture-bound sex
syndromes Koro Dhat   Conclusions Advantage
of categories Advantages of needs
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Frequency of antidepressant associated sexual
dysfunction TCAs and MAOIs
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Frequency of antidepressant associated sexual
dysfunctionSSRIs
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Frequency of antidepressant associated sexual
dysfunction newer antidepressants
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Antidepressants and sexual dysfunction
Arousal / Erection
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Antidepressants and sexual dysfunction (continued)
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Pharmacological reversal of antidepressant
induced sexual dysfunction target norepinephrine
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Pharmacological reversal of antidepressant
induced sexual dysfunction target serotonin
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Pharmacological reversal of antidepressant sexual
dysfunction target dopamine
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Pharmacological reversal of antidepressant
induced sexual dysfunction target acetylcholine
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Pharmacological reversal of antidepressant
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Pharmacological reversal of antidepressant
(continued)
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Complementary alternative medicine for treatment
of sexual dysfunction Yohimbine
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Complementary alternative medicine for the
treatment of sexual dysfunction other herbal
remedies
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Complementary alternative medicine for treatment
of sexual dysfunction other herbal remedies
continued
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Complementary alternative medicine for treatment
of sexual dysfunction other herbal remedies
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Effects of various factors including drugs on
sexual cycles
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PATIENT
Assessment Physical Exam
LAB. T/LH/T4/Glucose
Positive for Endocrine
Negative for Endocrine
- ve organic indication
ve organic indication
Med Rx
Doppler NPT
ve vasc insufficient
Negative
ve Neurogenic dysfunction
Sexual Counselling
Neuro testing
Vasc testing
Papaverine Cavernosometry
Medical/Surgical Therapy
Psychosexual Therapy
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Conclusions
Problems See physical cause Seek physical
treatment Joint therapy difficult Practical
difficulties in therapy - no privacy - living
with extended family - shortage of space

• Some treatment is better than none
• Long-term effects are unclear
• Little is known about outcome factors
• No evidence to suggest that one treatment method
  is superior to others

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