OUTLINE ○ Based on the physical components of sexual

functioning, they described four phases of

I. OVERVIEW VI. GENDER AND
the sexual response cycle: excitement,
II. SEXUAL DYSFUNCTION SEXUAL ORIENTATION
plateau, orgasm, and resolution
III. FEMALE SEXUAL A. Lesbian
DYSFUNCTION B. Gay men
IV. MALE SEXUAL C. Transgendered
DYSFUNCTION Patients
A. Erectile Dysfunction VII. SEXUALITY ISSUES AT
B. Premature (Early SPECIFIC TIMES OF
Ejaculation) LIFE
C. Delayed Ejaculation A. Adolescence
V. SUBSTANCE− OR B. Older Adulthood
MEDICATION− INDUCED VIII. CONCLUSION
SEXUAL DYSFUNCTION IX. REFERENCE

I. OVERVIEW

● Sexuality is a fundamental aspect of human

self-concept and a complex biopsychosocial
process.
● Physiologic aspects of sexuality are interpreted
within the patient’s cultural and social context. ● Psychologically Oriented Sexual Responsiveness
● Family physicians and primary care providers are Model
well situated to offer patients basic information ○ Proposed by Helen Singer Kaplan
regarding human sexual health issues and to ○ more subjective, with three phases: desire,
evaluate and treat most common sexual excitement, and orgasm.
problems; however, they seldom ask patients ● Nonlinear alternative models have been
about sexual functioning. suggested, especially for women’s sexual response
SEXUAL SELF-CONCEPT (Basson and Schultz, 2007) (Figure 42-2). In certain
● Androphilic - sexually attracted to men settings, men may have similar nonlinear sexual
● Gynephilic - sexually attracted to women responses.
● If desired sexual partners are their own gender,
INITIAL EVALUATION OF SEXUAL PROBLEMS
individuals may self-identify as gay or lesbian or, if
● Many patients would benefit from detection and
both genders, bisexual.
treatment of sexual problems; however, many
● Someone who falls outside the societal norms of
clinicians do not ask, and patients may not
gender or sexual attraction may self-identify as
volunteer the information.
“queer,” .
● In the Global Study of Sexual Attitudes and
● The terms “men who have sex with men” (MSM)
Behaviors (GSSAB), which surveyed more than
and “women who have sex with women” (WSW)
27,000 adults age 40 to 80 years in 29 countries,
are used because the sexual activity defines the
49% of women and 43% of men reported
risks, not the gender identity.
experiencing at least one sexual problem; fewer
MODELS OF HUMAN SEXUAL RESPONSE than 20% had sought medical assistance for sexual
● Physiology of the “human sexual response cycle” issues (Moreira et al., 2005).
○ First described by Masters and Johnson in ● Health care providers should proactively and
1966. routinely address sexual health.
● The sexual health interview may be approached

1 | Page
 with a screening or abbreviated method followed ● Slang words should be redefined in medical
by in-depth questioning if necessary (Table 42-1). terminology so that the clinician and patient may
● The answers on the detailed sexual history then communicate clearly.
direct the physical examination and appropriate ● PLISSIT model
laboratory testing. ○ Proposed by Jack Annon in 1976,
○ Used to approach sexual concerns:
Permission, Limited Information, Specific
Suggestions, and Intensive Treatment (Table
42-2).

● Many clinical cases can be managed with brief

education or limited advice, such as discussing
normal physiologic sexual changes with aging or
● Open the sexual history questioning with an recommending books or products (e.g.,
inclusion technique. water-based lubricant for vaginal dryness).
○ “Sexual health is important to overall health, ● When a referral has been made, scheduled
so I ask all my patients about it. I’m going to follow-up visits support the patient during the
ask you a few questions on sexual matters process.
now.” ● Counseling may be extremely important, and the
● Use normalization when introducing emotionally physician should research local resources
laden or difficult subjects by implying these
experiences are quite prevalent: II. SEXUAL DYSFUNCTION
○ “Many people have been sexually abused
or molested as children. Did you have any ● Sexual functioning
experiences like that when you were ○ physical, mental, emotional aspects
young?” interaction
● Universalization phrases questions as if everyone ● Sexual dysfunction (DSM-5)
has done everything, making an affirmative ○ “disorder” → must cause the individual
answer easier for sensitive questions. “clinically significant distress”
○ Patients may be asked, “How often do you ○ may be “lifelong,” or “acquired,” a
masturbate?” instead of “Do you ○ may be “generalized” or “situational,”
masturbate?” ○ severity: “mild,” “moderate,” or “severe”
● The clinician should also reassure the patient about ● Evaluation
physician- or clinician-patient confidentiality. ○ partner factors,
● Physicians should avoid terms that make ○ relationship factors,
assumptions regarding patients’ sexual behaviors. ○ individual vulnerability factors, psychiatric
● When inquiring about past or recent sexual comorbidity, life stressors,
encounters, the clinician may inquire “with men, ○ cultural or religious factors,
women, or both?” ○ medical factors
● Using the term “partner” instead of “husband,” ● Before diagnosis
“boyfriend,” “wife,” or “girlfriend” may allow ○ Rule out: patient’s perceived sexual
patients to discuss their sexual orientation openly. dysfunction is not better explained by a

2 | Page
 medical condition or treatment for a ○ Discord or communication difficulty in a
medical condition couple’s relationship
○ an individual’s understanding of sexual
functioning must be assessed EVALUATION
○ Occasionally, they simply lacks the ● Thorough history and physical examination
knowledge or an understanding of the ● Laboratory testing
normal decrease in sexual response ○ thyroid function -fasting glucose
associated with aging and needs ○ lipid profile -liver
education function
● If a hormonal problem is suspected
III. FEMALE SEXUAL DYSFUNCTION ○ Prolactin, total and free testosterone, sex
hormone–binding globulin,
FEMALE SEXUAL INTEREST/AROUSAL DISORDER dehydroepiandrosterone (DHEA), and
● Low sexual interest estrogen levels
○ Most frequently reported sexual problem. ● Androgen levels
○ 4 in 10 women have low sexual desire ○ Measured at the peak on days 8-10 of a
● Hypoactive sexual desire disorder (DSM-IV-TR) 28-day menstrual cycle in
● Female sexual interest/arousal disorder (DSM-5) premenopausal women
○ A woman needs to lack or have
significantly reduced sexual interest or FEMALE ORGASMIC DISORDER
arousal for at least a 6-month duration TREATMENT
○ Manifested by at least three of six criteria ● No U.S. FDA approved medication
● Estrogen therapy improves vaginal dryness
● Estrogen alone or in combination with
progesterone
○ Women within 5 years of amenorrhea
(early menopause)
● Ginkgo biloba, damiana leaf, ginseng, and other
proprietary herbal blends
○ Limited data exist
● Psychosocial interventions
○ Reported efficacious for the treatment of
female sexual dysfunction
● Orgasmic dysfunction
○ the inability to reach orgasm when desired
○ may be lifelong or acquired
● Women must have experienced a marked delay in
orgasm, marked infrequency of or absence of
orgasm, and markedly reduced intensity of
● Female sexual desire orgasmic sensations over a 6-month time frame
○ A complex interaction among biologic, ● Must express clinically significant distress regarding
psychological, social, interpersonal, and the diminished orgasmic sensations
environmental components.
EVALUATION
○ Ovarian function (ovarian androgens),
● Clinical history in acquired orgasmic disorder
may play an important role
○ patient’s perception of this dysfunction
● Factors that may diminish sexual interest or arousal
○ the time and circumstances of onset,
○ Life stressors, health problems, and
possible causes,
personality
○ effect on relationship(s), and treatment
○ Thyroid disease, chronic pain conditions,
goals.
urinary incontinence, and depression or
● Physiologic functioning during sexual stimulation
anxiety
● Contributing factors
○ SSRI antidepressants, antihypertensives,
○ fatigue, depression, stress, substance
antipsychotics, and narcotics
abuse, and other medical illnesses
○ Fear of pregnancy or sexually transmitted
● Contextual and relationship issues
infection (STI)
● SSRIs may delay or inhibit orgasm in women.

3 | Page
 ● No specific physical examination or laboratory IV. MALE SEXUAL DYSFUNCTION
testing is necessary
ERECTILE DYSFUNCTION
GENITO-PELVIC PAIN/PENETRATION DISORDER
● “the inability for a male to achieve an erect penis
Four commonly comorbid symptoms: as part of the overall multifaceted process of male
1. Difficulty having intercourse sexual function.” (NIHCDC, 1992)
● “erectile disorder” accompanied by “clinically
2. Genito-pelvic pain
significant distress” (DSM-5)
3. Fear of pain or vaginal pain
○ Not better accounted for by a nonsexual
4. Tension of the pelvic floor muscles mental health disorder of the direct
physiologic effects of a substance or a
Genito-pelvic pain is often idiopathic but may follow general medical condition
pelvic trauma, such as: ● Occur at any age, prevalence increases with age
● Painful intercourse ○ 2% (40-49 y/o), 6% (50-59 y/o), 17% (60-69
● Childhood or adolescent sexual abuse y/o, 39% (70 y/o)
● Sexual assault ● Associated with: DM, CAD, CVD, HPN
● Rough gynecologic examination ● Other contributing factors: Smoking, sedentary
● Complicated episiotomy lifestyle overweight
● Vaginal infections
● Pelvic inflammatory disease EVALUATION
● Pelvic surgery ● Some men consider PE as ED
● Check Medicines
EVALUATION ● Social History: smoking, alcohol, drug and
● Diagnosis: History marijuana use and important social and sexual
relationships
● Important risk factor: Pain during tampon insertion
● Psychological factors: depression and anxiety
or the inability to insert a tampon
● Physical activity: bicycle riding (decreased penile
● Pain and difficulty with, or inability to engage in, blood flow from perineal compression)
vaginal intercourse or digital vaginal stimulation,
using tampons or vaginal contraceptives, or
having a pelvic examination
● Speculum exam: Visible contraction of the pelvic
floor musculature
● Physical exam: Pertinent anatomic abnormalities
(vaginal septa)

TREATMENT
● Vaginal muscle tightening or spasm: restoring
conscious control of vaginal muscle relaxation
● Expresses fear or anxiety: pelvic examination may
be deferred
○ Severe cases: sedation
● Any physical abnormalities detected (infections),
should first be treated
● Self treatment (size-graded plastic or silicone
vaginal dilators)
○ Vagina remain relaxed and receive
nonpainful, self-controlled penetration
● Specialized PT: Patients use biofeedback to relax
the pelvic floor musculature PHYSICAL EXAMINATION
● vascular, neurologic, and endocrine systems
○ Peripheral pulses and carotid
○ Thyroid enlargement or nodular diseases

4 | Page
 ● Genitourinary examination diagnosis of delayed ejaculation disorder
○ perineal innervation with anal sphincter
tone, perianal sensation, and the CAUSES
bulbocavernosus reflex ● Alcohol use
○ Penile shaft (Peyronie disease) ● Contextual issues
○ Prostate and testicle (atrophy), signs of ● Partner issues
hypogonadism
● Glucose, lipid profile, BUN, creatinine, serum V. SUBSTANCE− OR MEDICATION− INDUCED SEXUAL DYSFUNCTION

transaminases, TSH, PSA and testosterone

evaluation Substance-Induced Sexual Dysfunction
Common -Alcohol, Opioid narcotics,
TREATMENT substances Amphetamine, Cocaine
● Phosphodiesterase-5 inhibitors: first-line therapy
Antidepressants, -Inhibited or delayed orgasm in both
● Prostaglandin E1 (PGE1; alprostadil): second-line
especially SSRIs or men and women
treatment
● Vacuum erectile devices tricyclics -Erectile dysfunction (ED) in men
● Penile prosthesis
Anticonvulsants,
● Alternative medicine: ginseng and yohimbine -Adverse effects on sexual desire
except lamotrigine
● Psychotherapy or psychotherapy + sildenafil
Gabapentin -May affect orgasm
PREMATURE (EARLY EJACULATION)
-Lowers testosterone levels in men,
● Ejaculation that occurs BEFORE or SHORTLY after
Chronic opioid use which may cause decreased libido
vaginal penetration
or ED
● 60 seconds or less intravaginal latency
● All men regardless of sexual activities or partners ● For men with ED from SSRIs, administering sildenafil
● Using DSM-5: 1-3% men diagnosed with ejaculation appears effective
within 1min of vaginal penetration
● Using DSM-4: 20-30% men diagnosed with
VI. GENDER AND SEXUAL ORIENTATION
ejaculation occurring more rapidly than desired

EVALUATION ● Sexual orientation is a social construct

● Through history taking ● Customs regarding which sexual acts are
● Includes: acceptable, with whom, and under what
○ Young men whose 1st sexual experiences circumstances have varied in different cultures
were rushed and eras
○ Men having intercourse infrequently ● In Sexual Behavior in the Human Male in 1948,
○ Conditions like hyperthyroidism and Kinsey and colleagues hypothesized that sexual
prostatitis orientation might be a continuous spectrum, from
● Determine exclusive heterosexuality through exclusive
○ If patient can delay ejaculation when homosexuality, and might vary across the life span
masturbating in different people
○ Sexual knowledge
○ Partner’s expectations

TREATMENT
● Selective serotonin reuptake inhibitors
● PDE-5 Inhibitors
● Topical eutectic mixture of lidocaine- prilocaine
spray

DELAYED EJACULATION
● Diagnosed when the man has adequate sexual
stimulation and the desire to ejaculate but
subjectively has a delay or absence of ejaculation
● Fewer than 1% of men complains of delayed
ejaculation listing the 6 months needed for the

5 | Page
 VII. SEXUALITY ISSUES AT SPECIFIC TIMES OF LIFE
LESBIAN
● Lesbians are less likely to obtain health
maintenance services (mammography and ADOLESCENCE
cervical cancer screening) than heterosexual Sexual Activity
women ● Teenagers may practice sexual acts other than
● Nulliparous lesbians intercourse
○ High risk for cancers of the breast, ○ mutual genital touching
endometrium, and ovary ○ masturbation
● Female-to-female transmission of STIs is much less ○ oral sex
efficient than male-to-female transmission ● Remind sexually active adolescents to use a
● Genital–oral sex and fomites (sex toys) condom
○ Can transmit gonorrhea and Trichomonas ● 47% of all students had sexual intercourse
● Mental health screening for depression and suicide ● 15% of teenagers had four or more sexual partners
should be considered, especially for “closeted” ● Do not assume that adolescent sexual experiences
sexual minority women are consensual or desired
● Lesbians who had not disclosed their sexual ● Drug and alcohol use is a significant risk factor for
orientation to a majority of friends, family, and unprotected sexual activity
coworkers were 90% more likely to have ever ● Referral for treatment of addiction
made a suicide attempt ○ drinking with driving or sex
○ unable to discontinue this risk behavior
GAY MEN without assistance
● Gay men sometimes report difficulty in obtaining ● Long-acting contraception - young women who
adequate health care caused by providers’ bias are at risk for pregnancy because of substance
and fear of discrimination use
● Men who self-identify as gay or bisexual are more
LGBTQ
likely than heterosexual men
● Lesbian, Gay, Bisexual, and Transgender and
○ To have major depression
Questioning Youth
○ To admit to suicidal ideation
● 3 dimensions of sexual orientation
○ To have attempted suicide
○ Attraction
TRANSGENDERED PATIENTS ○ Self-identification
● Transgendered individuals transiently or persistently ○ Sexual behavior
identify with a gender different than their natal ● “Questioning” - uncertain of their sexual orientation
gender ● Maintain an open questioning style
● A transsexual individual
Gender Dysphoria
○ One who seeks to take on the social role of
● By 3 or 4 years, a child self identifies as a boy or girl
the other gender, either full or part time,
● some children may express gender dysphoria as
often with the assistance of hormone
early as preschool
therapy, surgery, or both
● Gender dysphoric adolescents may have more
● Cross-dressers (previously referred to as
anxiety and depression or oppositional defiant
“transvestites”)
disorder than non– gender dysphoric adolescents
○ Persons who at times may dress as the
other gender to be publicly perceived as Health Risks for LGBTQ Youth
such or for sexual pleasure. ● harassment, profound isolation, and fear of
● Intersex discovery
○ Persons born with ambiguous genitalia or ● Censure, alienation, and abandonment by the
for whom phenotypic and chromosomal family of origin
sex do not match ● more likely to
● Gender dysphoria is clinically distressing ○ have had sexual intercourse
incongruence between one’s natal gender and ○ have had three or more sexual partners
one’s expressed or experienced gender ○ experience sexual intercourse against their
○ People may seek medical assistance in will
changing their physical sex to be ○ start using tobacco, alcohol, and illegal
congruent with their internal drugs at an earlier age
self-perception

6 | Page
● become pregnant than their heterosexual peers significant vaginal atrophy through continued
● sexual activity while under the influence of drugs or stimulation of the epithelium and vascular supply
alcohol ● Testosterone levels do decline with age, eventually
● half as likely to use a condom by 50% from midlife to old age.
● Depression and suicide ● Testosterone levels are lower in men with chronic
illnesses than healthy men
OLDER ADULTHOOD ● Signs and symptoms of low testosterone levels:
● The likelihood of being sexually active correlates ○ increased abdominal fat - reduced muscle
with good health status. and bone mass
● Testosterone levels are lower in men with chronic ○ decreased body hair - Gynecomastia
illnesses than in healthy men ○ small testis - Fatigue
● Before testosterone replacement, men should ○ Weakness - decreased libido
have their prostates evaluated with a PSA and ○ decreased energy - erectile dysfunction
digital rectal examination. ● Low testosterone levels associated with signs and
● the likelihood of being sexually active declines symptoms compromise the clinical syndrome of
steadily with age, many older adults remain late-onset hypogonadism, also called androgen
sexually active deficiency in the aging male or colloquially “low
● The likelihood of being sexually active is associated T.”
with good health ● Testosterone levels above 12 nmol/L (346 ng/dL)
● Common health conditions that can inhibit sexual do not need supplementation
activity ● In obese men, weight loss and increased physical
○ Arthritis or back pain activity can raise testosterone levels
○ Vascular disease and its risk factors ● Before testosterone replacement therapy (TRT),
(correlate with ED) men should be screened with a PSA and a digital
■ CAD rectal examination and then have a PSA drawn
■ Stroke annually
■ Diabetes ○ A PSA rise of 0.4 ng/mL over 2 years or an
■ Hypertension incremental rise of 1.4 ng/mL in 1 year
■ Hyperlipidemia should trigger further urologic examination
■ smoking ● Testosterone for replacement can be administered
○ Pudendal nerve disruption after intramuscularly, subcutaneously, or transdermally
hysterectomy and bladder, rectal, or ● Testosterone supplementation appears to have
prostate surgery increased risk for men with cardiovascular disease.
● At all ages, women are less likely to be sexually
active than men. VIII. CONCLUSION
● For women who reported no sexual activity in the
previous 3 months: ● Sexuality is a core aspect of personal identity
○ lack of interest - most common reason ● Many patients with sexual problems can be
○ lack of a sexual partner treated by family physicians and other primary
○ physical problem of the partner health care providers without assistance
○ lack of interest by the partner ● Family physicians should maintain awareness of
● Between 75 and 85 years, men are almost twice as the health care needs of persons with
likely as women to have an intimate partner same-gender sexual experiences or orientation
● A decline in sex steroid production is a factor in ● Sexual health issues are pertinent for adolescent
sexual dysfunction for both women and men and older adult wellhealth care
● Postmenopausal estrogen deficiency is responsible ● Family physicians should routinely include
for loss of vaginal lubrication and elasticity questions regarding gender identity, sexual
● The Women’s Health Initiative raised concerns behavior, and relationships during the clinical
regarding deleterious effects of systemic estrogen interview of all patients to help maintain their
replacement optimum health.
○ Clinicians should counsel women desiring
long-term oral estrogen supplementation to IX. REFERENCE
diminish vaginal atrophy symptoms
regarding the increased risk of CAD, ● Reporters ppt
thrombotic disease, and breast cancer
● Women who remain sexually active may avoid

7 | Page