++
There are three major groups of sexual disorders.
++
In these conditions, formerly called “deviations” or “variations,” the excitement stage of sexual activity is associated with sexual objects or orientations different from those usually associated with adult sexual stimulation. The stimulus may be a woman’s shoe, a child, animals, instruments of torture, or incidents of aggression. The pattern of sexual stimulation is usually one that has early psychological roots. When paraphilias are associated with distress, impairment, or risk of harm, they become paraphilic disorders. Some paraphilias or paraphilic disorders include exhibitionism, transvestism, voyeurism, pedophilia, incest, sexual sadism, and sexual masochism.
++
Exhibitionism is the impulsive behavior of exposing the genitalia to unsuspecting strangers in order to achieve sexual excitation. It is a childhood sexual behavior carried into adult life.
++
Transvestism consists of recurrent cross-dressing behavior for the purpose of sexual excitation. Such fetishistic behavior can be part of masturbation foreplay.
++
Voyeurism involves the achievement of sexual arousal by watching the activities of an unsuspecting person, usually in various stages of undress or sexual activity. In both exhibitionism and voyeurism, excitation leads to masturbation as a replacement for sexual activity.
++
Pedophilia is the use of a child of either sex to achieve sexual arousal and, in many cases, gratification. Contact is frequently oral, with either participant being dominant, but pedophilia includes intercourse of any type. Adults of both sexes engage in this behavior, with exact prevalences unknown, but likely far less common among females.
++
Incest involves a sexual relationship with a person in the immediate family, most frequently a child. In many ways it is similar to pedophilia (intrafamilial pedophilia). Incestuous feelings are fairly common, but cultural mores are usually sufficiently strong to act as a barrier to the expression of sexual feelings.
++
Sexual sadism is the attainment of sexual arousal by inflicting pain upon the sexual object. Much sexual activity has aggressive components (eg, biting, scratching). However, forced sexual acquiescence (eg, rape) is an act of aggression.
++
Sexual masochism is the achievement of erotic pleasure by being humiliated, enslaved, physically bound, and restrained. It may be life-threatening, since neck binding or partial asphyxiation usually forms part of the ritual. The practice is much more common in men than in women.
++
Gender dysphoria is distress associated with the incongruence between one’s experienced or expressed gender and one’s assigned gender. As a disorder, it is defined by significant distress or impairment; those experiencing this incongruence but without the distress would not meet criteria for having gender dysphoria. Screening should be done for conditions related to the oppression and stigmatization that transgender people face, including a high risk of suicide.
+++
C. Sexual Dysfunctions
++
This category includes a large group of vasocongestive and orgasmic disorders. Often, they involve problems of sexual adaptation, education, and technique that are often initially discussed with, diagnosed by, and treated by the primary care provider.
++
There are two conditions common in men: erectile dysfunction and ejaculation disturbances.
++
Erectile dysfunction is inability to achieve or maintain an erection firm enough for satisfactory intercourse; patients sometimes use the term incorrectly to mean premature ejaculation. Careful questioning is necessary, since causes of this vasocongestive disorder can be psychological, physiologic, or both. The majority are pathophysiologic and, to varying degrees, treatable. After onset of the problem, a history of occasional erections—especially nocturnal penile tumescence, which may be evaluated by a simple monitoring device, or a sleep study in the sleep laboratory—is usually evidence that the dysfunction is psychological in origin. Decreased nocturnal penile tumescence occurs in some depressed patients. Psychological erectile dysfunction is caused by interpersonal or intrapsychic factors (eg, partner disharmony, depression). Organic factors are discussed in Chapter 23.
++
Ejaculation disturbances include premature ejaculation, inability to ejaculate, and retrograde ejaculation. (Ejaculation is possible in patients with erectile dysfunction.) Ejaculation is usually connected with orgasm, and ejaculatory control is an acquired behavior that is minimal in adolescence and increases with experience. Pathogenic factors are those that interfere with learning control, most frequently sexual ignorance. Intrapsychic factors (anxiety, guilt, depression) and interpersonal maladaptation (partner problems, unresponsiveness of mate, power struggles) are also common. Organic causes include interference with sympathetic nerve distribution (often due to surgery or radiation) and the effects of pharmacologic agents (eg, SSRIs or sympatholytics).
++
In women, the most common forms of sexual dysfunction are orgasmic disorder and hypoactive sexual desire disorder.
++
Orgasmic disorder is a complex condition in which there is a general lack of sexual responsiveness. The woman has difficulty in experiencing erotic sensation and does not have the vasocongestive response. Sexual activity varies from active avoidance of sex to an occasional orgasm. Orgasmic dysfunction—in which a woman has a vasocongestive response but varying degrees of difficulty in reaching orgasm—is sometimes differentiated from anorgasmia. Causes for the dysfunctions include poor sexual techniques, early traumatic sexual experiences, interpersonal disharmony (partner struggles, use of sex as a means of control), and intrapsychic problems (anxiety, fear, guilt). Organic causes include any conditions that might cause pain in intercourse, pelvic pathology, mechanical obstruction, and neurologic deficits.
++
Hypoactive sexual desire disorder consists of diminished or absent libido in either sex and may be a function of organic or psychological difficulties (eg, anxiety, phobic avoidance). Any chronic illness can reduce desire as can aging. Hormonal disorders, including hypogonadism or use of antiandrogen compounds such as cyproterone acetate, and chronic kidney disease contribute to deterioration in sexual desire. Alcohol, sedatives, opioids, marijuana, and some medications may affect sexual drive and performance. Menopause may lead to diminution of sexual desire in some women, and testosterone therapy is sometimes warranted as treatment.