1. Prof. Dr. Fareed A. Minhas
Head, Institute of Psychiatry
Rawalpindi General Hospital
Rawalpindi

2. DSM IV
ICD 10
Sexual Dysfunction
Sexual Dysfunction not due to
organic disorders
Sexual Desire disorders
Lack/loss of desire
Sexual arousal disorder
Aversion/Lack of enjoyment
Orgasm disorders
Failure of genital response
Sexual pain disorders
Orgasmic dysfunction
Dysfunction due to medication
Premature ejaculation
Non-organic pain disorders
Paraphilias
Excessive sexual drive
Disorders of sexual preference
Exhibitionism / Fetishism
Exhibitionism / Fetishism
Frotteurism / Paedophilia
Paedophilia / Sadomasochism
Sexual Masochism / Sadism
Voyeurism / Transvertism
Voyeurism / Transvertism
Gender Identity Disorders
Gender Identity Disorders
In children
In adolescents and adults

3. SEXUAL DYSFUNCTION
 Affecting sexual desire – Low libido
 Impaired sexual arousal – Erectile Impotence in men
Failure of arousal in women
 Affecting orgasm – Premature / Retarded ejaculation
Female orgasmic disorder
 Sexual pain disorders – Dyspareunia
Vaginismus
 Sexual dysfunction due to general medical conditions
HOMOSEXUALITY
In men / In women

4. SEXUAL DEVIATIONS
 Variations of the sexual object – Fetishism;Transvestitism
Pedophilia; Bestiality;
Necrophilia
 Variation of the sexual act – Exhibitionism; Voyeurism;
Sadism; Masochism;
Frotteurism
• DISORDERS OF GENDER IDENTITY
 Transexualism
 Gender disturbance in children

5. 93% of men, 28% of women masturbated by age
of 20
37% of men had experienced homosexual
orgasm
4% of men had experienced only homosexual
orgasm
Men show peak of sexual activity in late
adolescence
Women show peak of sexual activity in early
30’s
75% of Male achieve orgasm within 2 minutes of
penetration

6. Erectile impotence 0-1% under 20 years , 6.7%
40-50 years; 7.5% over 70
75% of women achieve orgasm in first year of
marriage
11% of boys, 6% of girls had intercourse by age
16; 30% of boys, 16% of girls had intercourse by
age 18
40% of married men report some degree of
impotence
60% of married women report some degree of
orgasmic dysfunction

7. HORMONAL
SYSTEM
INVOLVED
IN THE SEXUAL
CYCLE
IN
FEMALES

8. HORMONAL SYSTEM INVOLVED IN THE
SEXUAL CYCLE OF MEN

9. DESIRE
AROUSAL
PLATEAU
ORGASM
RESOLUTION
Affected by social,personal,cultural,
Hypothalamic and hormonal factors
Excitement mediated by PNS; genital
vasoconstriction leading to erection in male
and swelling or lubrication in females
Maintenance of arousal state
Emission-male only;Ejaculation in male and
equivalent in female mediated by SNS
With longer refractory period in the male
(can be 24 hours if over 60) and very short
refractory period in female (allowing for
multiple orgasm)
Masters & Johnson (1966), Kaplan (1978)

10. ERECTILE IMPOTENCE
Inability to sustain an erection adequate for
penetration. Most common disorder presenting in males
at clinics
EJACULATORY IMPOTENCE
Inability to ejaculate after adequate erection.
Uncommon
PREMATURE EJACULATION
Ejaculation before, during or immediately after
penetration. Usually in young men common
ANORGASMIA
(frigidity) orgasm achieved rarely or never

11. CHANGING ATTITUDES
About 25% of male have no orgasm during intercourse
for the first years of marriage.
SOME REQUIRE:
Stimulation of clitoris and vagina.
1/3 only vaginal stimulation. 10%
an-orgasmic
ANOTHER STUDY:
20% male rarely orgasmic
50% male sometimes
30% male nearly always

12. VAGINISMUS
Involuntary contraction of vaginal introitus in response
to attempts at penetration
Reasons:
 Fear about penetration
 Scarring after episiotomy
 Guilt of relationship
• DYSPAREUNIA
Pain on intercourse
Causes:
Impaired lubrication
Scars or other painful lesions,
Muscle spasm
Pelvic pathology(Endometriosis ovarian cyst
tumors pelvic infection)

13. FACTORS COMMON TO ALL DYSFUNCTIONS
Poor general relationship with the partner
Low sexual drive
Ignorance about the sexual technique
Anxiety about the sexual performance
Physical illnesses / Drugs (detailed in slides that follow)
PARTICULAR CONDITIONS
Male erectile disorder : Primary / Secondary / Abnormal
vascular supply of local region
Female orgasmic disorder : normal variations /
combination of above factors

14. MEDICAL AND SURGICAL CONDITIONS
COMMONLY ASSOCIATED WITH SEXUAL
DYSFUNCTIONS
MEDICAL
Endocrine
Diabetes, hyperthyroidism, myxoedema, Addisons
disease, hyperprolactinemia
Gynaecological Vaginitis, endometriosis, pelvic infections
Cardiovascular Angina pectoris, previous myocardial infarction
Respiratory
Asthma, Obstructive airways disease
Arthritic
Arthritis from any cause
Renal
Renal failure with or without dialysis
Neurological
Pelvic autonomic neuropathy, spinal cord lesions
stroke
SURGICAL
Mastectomy; Colostomy; ileostomy; oophorectomy
Episiotomy; operations for prolapse
Amputation

15. DRUGS MOST COMMONLY ASSOCIATED
WITH SEXUAL DYSFUNCTION
Alcohol
Anti Hypertensives:
Guanethidine, beta adrenoceptor
antagonists, methyl dopa.
Anti depressants:
TCA, MAOI inhibitors.
Anxiolytics and Hypnotics: Benzodiaziprines, Barbiturates
Anti psychotics:
Thioridazine.
Anti Inflammatory Drugs: Indomethacin.
Anti Cholinergic Drugs:
Probanthine.
Diuretics:
Bendrofluazide.
Hormones:
Steroids, possibly oral
contraceptives

16. IMPORTANT POINTS IN THE PHYSICAL
EXAMINATION OF MEN WITH SEXUAL
DYSFUNCTION
General Examination (directed especially to evidence
of Diabetes Mellitis,thyroid or adrenal disorder)
Hair Distribution
Gynaecomastia
Blood pressure and peripheral pulses
Ocular Fundi / Reflexes / Peripheral Sensation
Genital Examination
Penis : congenital anomalies;foreskin;pulses;tenderness;
plaques;infections;urethral discharge
Testicles : size; symmetry; texture; sensation

17. MASTERS & JOHNSON (1970)
 Partners are treated together:
 Helped to communicate better.
 They are taught the anatomy and physiology of sexual
intercourse.
 Given graded series of “Sexual Tasks” sensate focus:
Mutual Masturbation. Prohibit penetration.Prohibit
‘spectator role’
 Intensive treatment: Everyday × 3 weeks
 Male and female therapist
SPECIAL TECHNIQUES:
DYNAMIC PSYCHOTHERAPY
Squeeze technique
Start stop technique
Relaxation training(Vaginismus)
Use of vibrator (Anorgasmia)
Masturbation

18. HAWTHORN 1980: Best results obtained with vaginismus
and premature ejaculation
RESULTS GOOD:
evaluated
HORMONES:
-
Short duration of illness.
No serious marital problem.
No Psychiatric problem.
No adequate controlled trials:
Psychotherapy
not
been
in controlled trials.
Testosterone in hypogonadism.
No evidence that testosterone
improves impotence unless gross
endocrine disorder
Bromocryptine has been used for
impotence
Generally no convincing evidence

19. MASTERS & JOHNSON (1970)
Primary Impotence:
50% cure
Secondary Impotence:
70 – 80% cure
Pre-mature ejaculation:
100% cure
Female dysfunction:
80% cure
Study was carried out on erectile impotence by
Ansari (1976)
3 groups of patients presented with different
prognoses

20. Group 1
Group 2
Group 3
Acute onset
Short duration.
Insidious onset
Insidious onset
chronic relationship
With no
problems
discoverable
Precipitant present. Often decrease sexual
Precipitants
response in partner
(acute or
chronic)
Younger age(av 30)
often history of
Often unmarried.
older age: av. 45
low sex drive
older age: av: 45
Good Prognosis
With treatment.
Unlikely to relapse.
Good Result &
Treatment, but
likely to relapse.
Poor Prognosis.
Unlikely to respond
to treatment.

21. For centuries, variations in sexual act were regarded as
offences against the laws of religion rather than
disorders that doctors should study and treat
Nowadays the concept of sexual deviance has 3 aspects:
SOCIAL
PERSONAL
SUFFERING
HARM
TO OTHERS

22. The term denotes erotic thoughts and feelings
towards a person of the same sex, whether or
not they are associated with overt sexual
behavior
 THE CONTINUUM -
EXCLUSIVELY
EXCLUSIVELY
HOMOSEXUAL
HETEROSEXUAL

23. Behavior includes: Oral-genital contact mutual masturbation,
less often anal intercourse.Partners usually change voles.
(Passive vs active) Relationship does not last long
Some exclusively homosexual male experience strong feelings
of identity towards other homosexuals and adopt the
corresponding social behavior e.g. club, bars, dress in
effeminate style of life, and female mannerisms
Homosexual men vary in personality as much as do other male
Many homosexuals male live as happily as those who are
heterosexual. For others homosexuality leads to difficulties
with change with increasing age.
Middle age → loneliness, isolation, and depression particularly
if male has not previously established stable relationship, this
leads to relationships:homosexual prostitutes,prepubertal
children.

24. Behavior: Mutual masturbation, oral-genital contact,
caressing and breast stimulation.Small university: full body
contact with genital friction or pressure, vibrator or artificial
penis
Active and passive roles are interchanged
Social behavior of lesbians is usually unremarkable
All kinds of personalities are represented among female
lesbians. Most lesbians engage in heterosexual relationships
at some time even though they obtain less satisfaction.
Legal aspects of homosexuality
No laws specifically concerning homosexual behavior between
female
England/Wales: ↑ 21, in private, between consenting males
is not an offence

25. Various unproven theories. Most refer to male.
 GENETICS:
MZ twins have higher concordance than DZ
 PRENATAL FACTORS:
Hormonal influences e.g. androgens, at critical periods
of brain development. ‘Effeminate’ boys are more likely
to become homosexual
 ENVIRONMENTAL FACTORS:
Absent or unsatisfactory father and close binding
relationship with mother said to be important

26.  Shy and sexually in experienced young men who fear that
they may be homosexual but in fact are not
Young male who have realized that they are predominantly
homosexual; bewildered about the implications for their lives
Men who have bisexual inclinations; want to discuss ways of
arranging their lives appropriately
Established homosexual who becomes depressed or anxious
for personal/social difficulties arising from sexual relationship
Doctors principal role is to help the patient to clarify his
thoughts. **
Occasionally: Behavior modification of patients homosexual
impulses and behavior.
?? Psychoanalysis and psychotherapy: without convincing
evidence.