1.What is Sexuality ?
Normal Sexuality-Sexuality is determined by anatomy, physiology, the culture in which the person lives, relationships with others, and developmental experiences throughout the life cycle. It includes the perception of being male or female and private thoughts and fantasies as well as behavior. Sexual attraction to another person and the passion and love that follow are deeply associated with feelings of intimate happiness.
Normal sexual behavior brings pleasure to oneself and one’s partner and involves stimulation of the primary sex organs including coitus; it is devoid of inappropriate feelings of guilt and anxiety and is not compulsive. Societal understanding of what defines normal sexual behavior is inconstant and varies from era to era, reflecting culture mores of the time.
Sexual identity is the pattern of person’s biological sexual characteristics: chromosomes, external genitalia, internal genitalia, hormonal composition, gonads, and secondary sex characteristics. In normal development, these characteristics form a cohesive pattern that leaves a person in no doubt about his or her sex.
Gender identity is a person’s sense of maleness or femaleness. Gender identity results from an almost infinite series of cues derived from experiences with family members, teachers, friends and coworkers., and from cultural phenomenon.
Sexual Orientation describes the object of a person’s sexual impulses: heterosexual ( opposite sex ), homosexual ( same sex), or bisexual ( both sexes). A group of people have defined themselves as ” asexual” and assert this a positive identity.
Masturbation is usually a normal precursor of object related sexual behavior. Nearly all male and three fourth of all women masturbate sometimes during their lives. Moral taboos against masturbation have generated myths that masturbation causes mental illness or decreased sexual potency. No scientific evidence supports such claims. Masturbation is a psycho-pathological symptoms only when it becomes a compulsion beyond a person’s willful control.
2.What are Sexual Dysfunctions?
The essential features of sexual dysfunctions are an inability to respond to sexual stimulation, or the experience of pain during the sexual act. Dysfunction can be defined by disturbance in the subjective sense of pleasure or desire usually associated with sex, or by objective performance. Sexual dysfunction refers to a person’s inability “to participate in a sexual relationship as he or she would wish.
Hypo-active Sexual desire disorder is characterized by a deficiency or absence of sexual fantasies and desire for sexual activity for a minimum duration of approximately six months.
Male Erectile Disorder is defined as marked difficulty in obtaining an erection during sexual activity or until the completion of sexual activity or marked decrease in erectile rigidity for a minimum duration of approximately six months.
male erectile disorder can be organic or psychological , or a combination of both. If a man reports having spontaneous erection at times when he does not plan to have intercourse, having morning erections, or having good erections with masturbation or with partners other than his usual one, the organic cause of his erectile disorder can be considered negligible.
Delayed ejaculation is defined as marked delay in ejaculation or marked infrequency/absence of ejaculation for a minimum duration of approximately six months.
Premature ( Early) Ejaculation is defined as a persistent recurrent pattern of ejaculation occurring during partnered sexual activity with in approximately one minute following vaginal penetration and before the individual wishes it for a minimum duration of approximately six months.
Female Orgasmic Disorder is defined as the recurrent or persistent inhibition of female orgasm, as manifested by the recurrent delay in, or absence of orgasm after a normal sexual excitement phase.
Dyspareunia is recurrent or persistent genital pain occurring before, during, or after intercourse.
Vaginismus is defined as a constriction of the outer third of vagina due to involuntary pelvic floor muscle tightening or spasm, vaginismus interferes with penile insertion and intercourse.
3.What are different categories of sexual disorders?
2.Gender identity disorders
4.What are paraphilias?
Paraphilia is defined as a disorder in which a person experiences “recurrent, intense sexually arousing fantasies, urges, or behavior involving (1) nonhuman objects, (2) the suffering or humiliation of oneself or one’s partner, or (3) children or non-consenting adults.”
Patients may not be able to become sexually aroused unless involved with a paraphilia or may have an obsessive need to engage in the paraphiliac fantasy or behavior.
Types of paraphilias include:
Exhibitionism: sexual arousal from exposing one’s genitals to strangers.
Fetishism: use of nonliving objects—usually clothes—that the patient may hold, rub, smell, for sexual arousal.
Transvestic fetishism: cross-dressing, which usually is seen in heterosexual men, who find cross-dressing sexually arousing.
Pedophilia: fantasies, urges, or behaviors involving sexual activity with children.
Voyeurism: observing unsuspecting persons unclothed or involved in sex.
Sexual sadism: sexual arousal from inflicting suffering (physical or psychological on others).
Sexual masochism: sexual arousal from being hurt, humiliated, threatened, or made to suffer in some other way.
Frotteurism: touching or rubbing against a nonconsenting person.
The paraphilias are found almost exclusively in men. The difference between these and normal variations in sexual practices lies in the obligatory nature of the acts or
thoughts or the recurring, unrelenting need for such behaviors with less and less interest in usual sexual behaviors.
5.What is gender identity disorder?
Gender identity disorder is a condition wherein a person experiences a strong, persistent desire to be of the opposite sex or insists that he or she is in actuality of the opposite sex. Patients experience persistent, strong discomfort in their assigned sex. Physical examination is essential to rule out the rare instances of intersex conditions (e.g., congenital ambiguous genitalia, hypogonadism, androgen insensitivity syndrome) and may require lab studies such as testosterone/estrogen blood levels or karyotyping for sex chromosomes.
It is a situation where a child wants to be of the opposite sex. Even then, ambivalence about sexual identity in childhood usually disappears in adulthood. Many homosexual men report feeling different from other boys when they were young but never wanted to be girls; rather, they found no interest in the stereotypical sexual roles of boys.
Depression, anxiety, substance abuse, and personality disorder are common co-morbid conditions. Suicide attempts are not uncommon. Psychotherapy may be especially helpful when difficulties in interpersonal relationships, social isolation, or impaired self-esteem are paramount. A small percentage of patients seek sex-change surgery.
It is essential to differentiate this disorder from homosexuality. Homosexuality involves a sexual orientation to people of the same sex, not a wish for a man to become a woman or a woman to become a man. Sexuality includes sexual identity, sexual roles, and sexual orientation or choice. When individuals have different views on
sexual roles or different sexual orientation, they are not considered pathologic or disordered. Only gender identity problems are considered a psychiatric disorder.
6.What are the sexual dysfunctions?
Sexual dysfunction refers to problems in sexual desire, sexual arousal, sexual orgasm, or pain with sexual activity.
Sexual desire disorders include hypoactive sexual desire and sexual aversion disorder.
Sexual arousal disorders include both female arousal disorder and male erectile disorders, both of which involve difficulties in becoming sexually aroused even if sexual desire is present and normal.
Orgasmic disorders include female and male orgasmic disorders, e.g., difficulties in having orgasms or premature ejaculation in men.
Dyspareunia or vaginismus are disorders involving pain with sexual intercourse and may plague female patients.
The final categories are substance-induced sexual dysfunctions, and sexual dysfunction due to a medical condition, which underline the fact that sexual dysfunction may be caused by either biologic or psychologic causes.
7.What are common sexual concerns of men?
Most common is concern over the size of the penis, followed by worry about whether they are adequate lovers. Rarely do such concerns reflect a true disorder. Men are also commonly dissatisfied with the frequency or types of sexual contact with their spouse. The common sexual dysfunctions include inability to get an erection when one wants it, inability to maintain an erection long enough for intercourse, and reaching orgasm too quickly or conversely taking too long to ejaculate.
8.What are women’s concerns?
The most common concern of women revolves around orgasms, e.g., inability to achieve orgasms or not having orgasms with intercourse. The second most common area of concern is related to normalcy of sexual activities. Examples include whether it is permissible to have sex during menstruation; whether married people masturbate; or whether it is sick to have fantasies about someone other than one’s partner during intercourse. Finally, as with men, women voice concerns about tension between themselves and their spouse or mate, such as differences in how frequently they have sex and what kind of sexual behavior each wants or does not want.
9.Why may a woman not have orgasms with sexual intercourse?
Twenty to thirty percent of normal women do not have orgasms with intercourse. This is not a disorder or dysfunction but reflects inadequate clitoral stimulation during intercourse. Direct stimulation of the clitoral area—before, during, or after intercourse—may be required for such women to have orgasms. Manual or oral stimulation before vaginal containment or manual stimulation of the clitoris during intercourse may solve the problem. The woman may need more genital stimulation before intercourse than she has received. It is important for the woman to know that this variant of sexual response is normal and that many women require more than just intercourse for orgasm.
10.What is the difference between global and situational sexual disorders?
A global problem occurs in any setting, with any partner, and during masturbation. It is not related to time of day, type of sexual activity, or other variables. A situational problem, in contrast, occurs only with a certain person, situation, place, or time.
11.What drug causes the most sexual dysfunction?
Alcohol. Although alcohol loosens sexual inhibitions in a few people, much more often the opposite effect occurs and sexual function deteriorates. Even 1 or 2 drinks or beers may interfere with sexual desire or arousal. Illicit street drugs also may interfere with sexual function, including cocaine, narcotics, and marijuana.
12.What medical disorders commonly affect sexual functioning?
Depression typically interferes with sexual desire; mania classically increases desire or interest; and anxiety may interfere with performance, primarily arousal.
Any disease that affects the circulation may interfere with sexual arousal, including diabetes, hypertension, and atherosclerosis. Any disease that results in neuropathy, such as alcoholism, multiple sclerosis, or diabetes, may affect arousal and/or orgasm. Injury, irradiation, and retroperitoneal surgery may interfere with neuronal and vascular supply to the genitals and diminish or destroy arousal capability. Serious diseases that tax energy, such as congestive heart failure, chronic obstructive pulmonary disease, cancer, HIV with wasting, or chronic infections, diminish desire and arousal.
Endocrinopathy also may be a problem (e.g., thyroid disease, low testosterone or estrogen levels, prolactinemia, adrenal insufficiency).
13.What psychiatric disorders commonly interfere with sexual function?
Depression has as one of its hallmarks a lack of interest in activities that one used to enjoy. Sex is one of the most common activities in which the depressed patient has lost interest. Anxiety disorders probably interfere with sexual function as commonly as depression.
Many psychological bases for sexual dysfunction are not technically disorders or psychiatric diseases. Learned inhibition regarding sexuality and one’s body is common. Sometimes decreased interests in sex or difficulties with arousal are the ways of expressing anger at one’s mate. People who are ashamed of their body or feel unattractive may avoid sexuality. Patients may be afraid to have sex after myocardial infarction or stroke. Sexual disinterest not uncommonly starts during pregnancy or shortly after a child is born—for either the mother or father—and usually requires psychiatric treatment.
14.What is performance anxiety?
The classic patient with performance anxiety is the man whose anxiety about getting or maintaining an erection or having an orgasm causes the very problem about which he is so anxious. His sympathetic nervous system is so revved up from thinking and worrying that it prevents adequate sexual performance. They should stop worrying, thinking, and becoming anxious about his anticipated sexual prowess or inadequacy and just to let it happen.
Women also may have performance anxiety. They may be anxious about whether they will become aroused, have an orgasm, or please their partner or whether the sexual experience will be unpleasant.
15.Do any medications improve sexual function?
With the availability of new therapies (sildenafil,Tadanafil,Valdenafil), a large percentage of men now are able to have erections suitable for intercourse—whether the cause of the impotence is organic or psychological.
Estrogen and testosterone replacement in post-menopausal women improves libido and arousal.
It is likely that other medications to improve sexual interest and performance will be released in the next few years.
16.If a medical disorder prevents sexual arousal, what can be done to help?
Vacuum pump and penile implants are used in patients whose medical disorder precludes sexual arousal.
When none of the above are successful, the couple should find means of sexual pleasure and fulfillment without intercourse (e.g., cuddling, manual or oral stimulation of genitals, sensate focus).
17.What is the normal sexual development from birth to school age?
Infants are very much into exploring their bodies. They discover and explore feet, hands, ears, and genitals. They find that touching their genitals is a pleasant experience. This discovery may upset parents who may label such behavior as masturbation rather than exploration.
From 2–5 years of age children are interested in their genital anatomy and how it differs from people of the opposite gender. They are also quite interested in sexual roles, e.g., how males and females are similar and different in terms of games they play, what they enjoy, ways they talk. It is important to answer children’s questions with accurate and simple explanations. Although it may be embarrassing at times, it is quite important to handle children’s curiosity about sexuality in a matter-of-fact way, without heightening the feeling that the whole subject of sexuality is taboo.
18.What are children’s concerns about puberty?
Children are concerned whether they experience the physical changes of puberty later or earlier than their peers. Girls are especially self-conscious about breast development, because it seems so obvious to others. Being like other children is the key: not to be too tall or too short, not to develop too soon or too late. Girls may be terrorized by their first menstrual period (especially if it occurs without prior discussion and appropriate information), worrying that they are bleeding to death or sick or that other people can smell or sense that they are having the “curse.” A boy’s first nocturnal emission may be frightening, because the boy may think that he has wet the bed or that something is terribly wrong. Anticipatory education from parents or physician helps to reduce such anxieties.
19.Where do children get information about sex?
Most sexual information comes from friends and peers, not from parents, school, or books. Hence, their early sexual education is unreliable and often includes misinformation. Parents should give information about sex to their children.
20.Is it true that most elderly people do not have sex?
No. Frequency of sexual intercourse decreases, but most couples, if unfettered by medical disease, continue to have intercourse 2–4 times a month. Self-stimulation also continues in senior citizens.
21.What changes in sexual functioning occur with aging?
There is no abrupt change in sexual functioning. Changes in sexual ability start when people are in their 40s. In men the changes include:
- A need for more physical stimulation of the penis to induce erection
- Slower, less firm erection
- Longer time to reach orgasm
- Decreased force of ejaculation
- Longer time to get an erection after orgasm
- Fewer spontaneous erections
- Erections that come and go even during intercourse
- 22.What common changes in women’s sexuality occur with increasing age?
- Decreased vaginal lubrication and thinning of vaginal mucosa occur after menopause
- Sexual arousal occurs more slowly.
- Irritation of the urethra is more common.
- Sex may be more pleasurable without concern for pregnancy or the need to use birth control; orgasm may be easier to achieve.
23.What are Kegel exercises?
The person volitionally and repeatedly tightens the muscles of the perineum (muscle tightening that holds in urine, bowel movements, or flatulence) for 3–4 minutes. Doing these exercises a few times a day helps to keep the muscle tone of the perineum taut and more satisfactory for both partners during sex. This exercise is valuable for both men and women.
24.What is safe sex?
Safe sex is the concept of having sex without fear of contracting a sexual disease from one’s partner. In fact, there is only one method of truly safe sex—complete abstinence from sexual contact with another person. Other safe-sex practices are ways to decrease the risk of contracting a disease, but it is important to note that
none is 100% safe. Nonetheless, decreasing the odds of disease transmission is especially important for people having sex with strangers or multiple partners, people at high risk of carrying sexually transmitted disease, or people with new partners whose past or current sexual history is unknown.
The underlying concept is to avoid contact with bodily fluids of the other person—especially genital fluids or blood. The use of a condom is essential, whether vaginal, anal, or oral sex is practiced. Using nonoxynol-9 or other spermicides with the condom may provide additional safety. Because heat or rough treatment may ruin condoms, patients should be advised not to carry them in a wallet or the glove box of a car.
Low-risk behaviors for transmission of sexually transmitted diseases include mutual masturbation or dry kissing.
Low-to-moderate risk behaviors include vaginal or anal intercourse with condoms and oral sex without climax
High-risk behaviors include anal or vaginal intercourse without a condom, sharing sex toys, fisting, or any sexual behavior that may damage mucosal linings or draw blood.
25. What are different modes of treatment?
The major new medications to treat sexual dysfunctions are sildenafil and its congenors i.e., Tadanafil and Vardenafil. Dapoxetine is used to treat pre mature ejaculation. Antidepressants, Antianxiety agents and Hormones are also used.
Treatment focuses on the exploration of unconscious conflict, motivation, fantasy, and various interpersonal difficulties. One of the assumptions of therapy is that removal of conflicts allows the sexual impulse to become structurally acceptable to the ego, and thereby the patient finds appropriate means of satisfaction in the environment. Common modes of psychotherapy used are Dual-sex therapy, hypnotherapy and Behavior therapy.
Penile prosthetic devices are used for men with inadequate erectile responses who are resistant to other treatment methods or who have medically caused deficiencies.