The lecture has been given on Apr. 5th, 2011 by Dr. Saman Anwar.

1. Sexual and gender identity disorders Dr.Saman Anwar M.B.Ch.B, F.I.B.M.S(PSYCH)

2. What Is “Normal” vs. “Abnormal” Sexual Behavior? Cultural considerations Gender differences in sexual behavior and attitudes . Age Individual ability and difference and preference. Life stress, education, love,……etc. NO CUT LINE BETWEEN THE TWO!!!!!!!!

3. Sexual Response Cycle Desire - inc. fantasies Excitement - subjective pleasure, physiological changes. **Plateau: brief pleasurable period of time before orgasm.** Orgasm - peaking of pleasure, ejaculation or vaginal wall contractions Resolution - differs for sexes, refractory period Sexual Dysfunctions at any of first 3

4. SEXUAL RESPONSE CYCLE

5. Common sexual myths Men should not express their emotions. All physical contact must lead to sex. Good sex leads to a wild orgasm. Sex = intercourse. The man should be the sexual leader. Women should not initiate sex. Men feel like sex all the time. Women should always have sex when her partner makes sexual approaches. Sex is something we instinctively know about. Respectable people should not enjoy sex too much and certainly never masturbate. All other couples have (great)sex, several times a week, have an orgasm every time, and always orgasm simultaneously. If sex is not good, there is something wrong with the relationship.

6. Sexual Dysfunctions: An Overview Sexual Dysfunctions Affect desire, arousal, and/or orgasm Pain associated with sex can lead to additional dysfunction Males and Females Experience parallel versions of most sexual dysfunctions Affects about 43% of all females and 31% of males Most prevalent class of disorder in the United States Classification of Sexual Dysfunctions Lifelong vs. acquired Generalized vs. specific Psychological factors alone Psychological factors combined with medical conditions

7. Sexual Desire Disorders Hypoactive Sexual Desire Disorder Little or no interest in any type of sexual activity Masturbation, sexual fantasies, and intercourse are rare Accounts for half of all complaints at sexuality clinics Affects 22% of women and 5% of men Sexual Aversion Disorder Little interest in sex Physical / sexual contact – Extreme fear, panic, disgust 10% of males report panic attacks during sexual activity

8. Excessive sexual desire Occasionally increased sexual drive may occur, presenting as a problem for individuals, partners (on whom (unreasonable)demands are made), or careers (when sexual disinhibition occurs). Referred to as nymphomania (women) or satyriasis (men). Usually occurs in late teenage/early adulthood, secondary to a mood disorder (e.g. mania), in the early stages of dementia, associated with learning disability, secondary to brain injury, or as a side-effect of some drugs. Management Treatment should address any primary problem, general relationship issues. When the problem is persistent, specialist referral may be appropriate (for cognitive, behavioural, or, rarely, pharmacological therapy).

9. Sexual Arousal Disorders Male Erectile Disorder(IMPOTENCE) Difficulty achieving and maintaining an erection. may be secondary to alcohol, diabetes. Female Sexual Arousal Disorder Difficulty achieving and maintaining adequate lubrication Associated Features of Sexual Arousal Disorders Problem is arousal, not desire Affects about 5% of males, 14% of females Males are more troubled by the problem than females Erectile problems are the main reason males seek help

10. Orgasm Disorders Inhibited Orgasm: Female and Male Orgasmic Disorder Have adequate desire and arousal Unable to achieve orgasm Rare condition in adult males Most common complaint of adult females 25% of adult females report difficulty reaching orgasm Anxiety based? Retarded Ejaculation - usually no orgasm w/ partner, only masturbation. Premature Ejaculation Ejaculation before the man or partner wishes it to 21% of all adult males meet diagnostic criteria Most prevalent sexual dysfunction in adult males Common in younger, inexperienced males Problem declines with age

11. Sexual Pain Disorders Defining Feature Marked pain during intercourse Dyspareunia Extreme pain during intercourse Adequate sexual desire, arousal, and ability to attain orgasm Must rule out medical reasons for pain Affects 1% to 5% of men and about 10% to 15% of women. Vaginismus - involuntary contraction of muscles of outer third of vagina (5-17% of women) Related to sexual abuse?

12. Management Exclude physical causes of pain (e.g. infection, tender episiotomy scar, endometriosis, ovarian cyst). Provide information about ensuring adequate arousal, variation of intercourse positions to avoid (deep) penetration. Relaxation techniques (including Kegel's exercises) and (positive self-talk)may help reduce anxiety and ensure the woman feels (in control). Where deep pain is experienced after intercourse, this may be due to pelvic congestion syndrome (with symptoms similar to pre-menstrual syndrome) caused by accumulation of blood during arousal without occurrence of orgasm. Achieving orgasm (by intercourse, masturbation, or use of a vibrator) may help to alleviate this congestion. For complex cases, with vague or intermittent problems, associated secondary sexual or psychiatric problems, or when initial treatment is unsuccessful, referral to a specialist is indicated.

13. Causes of Sexual Dysfunctions Biological Contributions Physical disease and medical illness Prescription medications Use and abuse of alcohol and other drugs Psychological Contributions The role of “anxiety” vs. “distraction” The nature and components of performance anxiety Psychological profiles associated with sexual dysfunction Social and Cultural Contributions Negative scripts about sexuality Erotophobia – Learned negative attitudes about sexuality Negative or traumatic sexual experiences Poor interpersonal relationships, lack of communication

14. Medical Treatment of Sexual Dysfunction Erectile Dysfunction Viagra – Is it really the wonder drug? Injection of vasodilating drugs into the penis Penile prosthesis or implants Vascular surgery Vacuum device therapy Few Medical Procedures for Female Sexual Dysfunction Sex hormones: testosterone?!

15. Paraphilias Recurrent, intense sexually arousing fantasies, urges, or behaviors involving nonhumans, suffering of self or partner, children. (For some these are necessary for erotic arousal & always inc. in sexual activity; for other these occur episodically.) Main Types of Paraphilias Fetishism Voyeurism Exhibitionism Transvestic fetishism Sexual sadism and masochism Pedophilia

16. Fetishism Sexual attraction – Nonliving objects Objects can be inanimate and/or tactile Examples include rubber, hair, shoes, underwears, Usually many objects of fetishistic arousal, fantasy, urges Voyeurism Observing an unsuspecting individual undressing or naked Risk associated with “peeping” is necessary for arousal

17. Exhibitionism exposing genitals to (unsuspecting) stranger(s), most common sex crime in U.S., rare outside, involves shock & risk, often distant from victim, needs to display masculinity w/o having to perform. Element of thrill and risk are necessary for sexual arousal. Transvestic Fetishism Sexual arousal with the act of cross-dressing Males may show highly masculine compensatory behaviors Most do not show compensatory behaviors Many are married and the behavior is known to spouse. Frotteurism rubbing against nonconsenter( in tram way, bus, lines, crowd places). More common in young adults and could occur in females.

18. Sexual Sadism and Sexual Masochism Sexual Sadism Inflicting pain or humiliation to attain sexual gratification Sexual Masochism Suffer pain or humiliation to attain sexual gratification Relation Between Sadism and Rape Some rapists are sadists Most rapists do not show paraphilic patterns of arousal Sexual arousal to violent sexual and non-sexual material

19. Pedophilia Pedophiles – Sexual attraction to young children Incest – Sexual attraction to one’s own children Victims are typically children or young adolescents Pedophilia is rare, but not unheard of, in females Associated Features Most pedophiles and incest perpetrators are male Incestuous males may be aroused to adult women Pedophiles are not aroused by adult women Most rationalize the behavior Engage in other moral compensatory behavior (church)

20. Pedophilia: Medical Treatment Medications: The Equivalent of Chemical Castration Often used for dangerous sexual offenders Types of Available Medications Cyproterone acetate – Anti-androgen, reduces testosterone, sexual urges and fantasy Medroxyprogesterone acetate – Depo-provera, also reduces testosterone Triptoretin – A newer more effective drug that inhibits gonadtropin secretion Efficacy of Medication Treatments Drugs greatly reduce sexual desire, fantasy, arousal Relapse rates are high with medication discontinuation

21. Paraphilias: Causes and Assessment Associated with sexual and social problems and deficits Inappropriate arousal / fantasy learned early in life High sex drive plus suppression of urges / drive Psychophysiological Assessment of Paraphilias Deviant patterns of sexual arousal Desired sexual arousal to adult content Social skills and the ability to form relationships

22. Gender identity disorder

23. Strong, persistent identification w/ other sex Persistent discomfort w/ sex, inappropriateness in gender role. Person feels trapped in the body of the wrong sex Assume identity of the desired sex Male to female or female to male. The goal is not sexual Causes are Unclear Gender identity develops early – 18 and 36 months/age As child Cross dressing Cross sex roles Played w/ other sex Insisting is other sex

24. Sex-Reassignment Surgery Who is a candidate? – Basic prerequisites before surgery 75% report satisfaction with new identity Adjustment is better for Female-to-male conversions . It is very expensive, and takes years of preparation and maintenance, both biological and psychological. Psychosocial Treatment of Gender Identity Disorder Realign psychological gender with biological sex Few Large Scale Studies. Male to female transgendered people cannot bear children, and can have prostate cancer and other ‘male’ problems. However, transgendered people can have successful intimate and sexual relationships, they do have orgasms following gender reassignment. Medical treatment

25. Sexual orientation Heterosexual Homosexual Bisexual Not in DSM-IV

26. A portion of all sexual disorders can be prevented through education alone, but because our society generally shies away from providing such education, people end up with problems in sexual functioning. Additionally, we assume that sexual activity is ‘natural’ and that no education is necessary. This is not true, we all have to learn part of what successful sexual encounters entail.

27. Thank you