7.NORMAL HUMAN SEXUALITY AND SEXUAL DYSFUNCTIONS.pptx

Important

1. NORMAL HUMAN SEXUALITY AND SEXUAL DYSFUNCTIONS MODERATOR: Dr. Anitha R Associate Professor of Psychiatry, IMH. PRESENTER: Dr. Aditya.U Post Graduate 2nd Year, IMH

2. NORMAL HUMAN SEXUALITY Sexuality is determined by ; Anatomy physiology, The culture in which a person lives, Relationships with others and developmental experiences throughout the life cycle

3. PSYCHOSEXUALITY Sexuality and total personality - entwined that it is virtually impossible to speak of sexuality as a separate entity. The term psychosexual is therefore used to describe personality development and functioning, as these are affected by sexuality. Sexuality depends on four interrelated psychosexual factors: sexual identity, gender identity, sexual orientation, sexual behavior.

4. Sexual identity - pattern of a person’s biological sexual characteristics: chromosomes, external and internal genitalia, hormonal composition, gonads, and secondary sex characteristics. In normal development, these characteristics form a cohesive pattern that leaves individuals in no doubt about their sex.

5. Gender identity- individual’s sense of maleness or femaleness. By the age of 2 or 3 years, most children have a firm conviction that “I am a boy” or “I am a girl. Physical characteristics derived from a person’s biological sex (e.g., physique, body shape, and physical dimensions) interrelate with an intricate system of stimuli, including rewards, punishment, and parental gender labels, to establish gender goals.

6. Sexual orientation - object of a person’s sexual impulses: heterosexual (opposite sex), homosexual (same sex), bisexual (both sexes).

7. The central nervous system and sexual behavior Sexual behavior includes desire, receptivity, fantasies, pursuit of partners, autoeroticism, and all the activities engaged in to express and gratify sexual needs. It is an amalgam of psychological and physiological responses to internal and external stimuli. The Brain Cortex - involved both in controlling sexual impulses and in processing sexual stimuli that may lead to sexual activity. The limbic system - is directly involved with elements of sexual functioning.

8. Brainstem - sites exert inhibitory and excitatory control over spinal sexual reflexes. Brain Neurotransmitters – including dopamine, epinephrine, norepinephrine, and serotonin, are produced in the brain and affect sexual function. Dopamine - increase libido. Serotonin - inhibitory effect on sexual function. Spinal Cord- Sexual arousal and climax are ultimately organized at the spinal level.

9. Physiological Responses Sexual response -true psychophysiological experience. Arousal -triggered by both psychological and physical stimuli. levels of tension - experienced both physiologically and emotionally; Orgasm-normally a subjective perception of a peak of physical reaction and release occurs along with a feeling of well-being. Refractory Period Physical health, psychosexual development, psychological attitudes toward sexuality and attitudes toward one’s sexual partner are directly involved with, and affect, the physiology of human sexual response.

10. Male Sexual Response Cycle organ Excitement phase Orgasmic phase Resolution phase mental Lasts several minutes to several hours; heightened excitement before orgasm, 30 seconds to 3 minutes 3–15 sec 10–15 mins; if no orgasm, 0.5 to 1 Day skin Just before orgasm: sexual flush inconsistently appears; maculopapular rash originates on abdomen & spreads to anterior chest wall, face, and neck, and can include shoulders & Forearms Well-developed flush Flush disappears in reverse order of appearance; Inconsistently appearing film of perspiration on soles of feet & palms of hands penis Erection in 10–30 sec caused by vaso congestion of erectile bodies of corpus cavernosa of shaft; loss of erection may occur with introduction of asexual stimulus—e.g., loud noise ; with heightened excitement, size of glans and diameter of penile shaft increase further Ejaculation: emission phase marked by 3 to 4 contractions of 0.8 sec. of vas, seminal vesicles, prostate; ejaculation proper marked by contractions of 0.8 sec. of urethra & ejaculatory spurt of 12–20 in at age 18, decreasing with age to seepage at age 70 Erection: partial involution in 5–10 sec with variable refractory period; full detumescence in 5–30 mins

11. organ Excitement phase Orgasmic phase Resolution phase Scrotum and testis Tightening & lifting of scrotal sac & elevation of testes; with heightened excitement,50% increase in size of testes over unstimulated state and flattening against perineum, signaling impending ejaculation No change Decrease to baseline size because of loss of vasocongestion ; testicular and scrotal descent within 5–30 mins after orgasm; involution may take several hours if no orgasmic release takes place Cowper glands 2–3 Drops of mucoid fluid that contain viable sperm are secreted during heightened excitement No change No change other Breasts: inconsistent nipple erection with heightened excitement before orgasm Myotonia: semi spastic contractions of facial, abdominal, and intercostal muscles. Tachycardia: up to 175 beats/min Blood pressure: rises to 20–80 mm systolic; 10–40 mm diastolic Respiration: increased Loss of voluntary muscular control Rectum: rhythmic contractions of sphincter Heart rate: up to 180 beats/min Blood pressure: up to 40–100mm systolic; 20–50 mm diastolic Respiration: up to 40 respirations/min Return to baseline state in 5–10 min

12. Female Sexual Response Cycle organ Excitement phase Orgasmic phase Resolution phase Mental Lasts several min. to several hours; heightened excitement before orgasm,30 sec. to 3 mins. 3–15 seconds 10–15 minutes; if no orgasm, 0.5–1 day Skin Just before orgasm: sexual flush inconsistently appears; maculopapular rash originates on abdomen & spreads to anterior chest wall, face, and neck; can include shoulders and forearms Well-developed flush Flush disappears in reverse order of appearance; Inconsistently appearing film of perspiration on soles of feet and palms of hands Breasts Nipple erection in two-thirds of women, venous congestion and areolar enlargement; size increases to one-fourth more than normal Breasts may become tremulous Return to normal in approximately 0.5 hour

13. organ Excitement phase Orgasmic phase Resolution phase Clitoris Enlargement in diameter of glans and shaft; just before orgasm, shaft retracts into prepuce No change Shaft returns to normal position in 5–10 sec; detumescence in 5–30 min; if no orgasm, detumescence takes several hours Labia majora Nullipara: elevate and flatten against perineum Multipara: congestion and edema No change Nullipara: increase to normal size in 1–2 min Multipara: decrease to normal size in 10–15 mins Labia minora Size increase two to three times more than normal; change to pink, red, deep red before orgasm Contractions of proximal labia minora Return to normal within 5 min

14. organ Excitement phase Orgasmic phase Resolution phase Vagina Color change to dark purple; transudate appears 10–30 secs after arousal; elongation and ballooning; lower third constricts before orgasm 3–15 Contractions of lower third at intervals of 0.8 seconds Ejaculate forms seminal pool in upper two thirds; congestion disappears in sec. or, if no orgasm, in 20–30 min Uterus Ascends into false pelvis; labor-like contractions begin in heightened excitement just before orgasm Contractions throughout orgasm Contractions cease, and uterus descends to normal position Other Myotonia A few drops of mucoid secretion from Bartholin glands during heightened excitement Cervix swells slightly and is passively elevated with uterus Loss of voluntary muscular control Rectum: rhythmic contractions of sphincter Hyperventilation and tachycardia Return to baseline status in sec. to mins Cervix color and size return to normal, & cervix descends into seminal pool

15. Taking a Sex History I. Identifying data A. Age B. Sex C. Occupation D. Relationship status- single, married, number of times previously married, separated, divorced, cohabiting, serious involvement, casual dating (difficulty forming or keeping relationships should be assessed throughout the interview) E. Sexual orientation —heterosexual, homosexual, or bisexual (this may also be ascertained later in the interview)

16. II. Current functioning A. Unsatisfactory to highly satisfactory B. If unsatisfactory, why? C. Feelings about partner satisfaction D. Dysfunctions ? 1. Onset —lifelong or acquired a. If acquired, when? b. Did onset coincide with drug use, life stresses, interpersonal difficulties? 2. Generalized —occurs in most situations or with most partners 3. Situational E. Frequency —partnered sex (coital and noncoital sex play) F. Desire / libido —how often are sexual feelings, thoughts, fantasies, dreams, experienced (per day, week, etc.)?

17. G. Description of typical sexual interaction 1. Manner of initiation or invitation (e.g., verbal or physical? Does same person always initiate?) 2. Presence, type, and extent of foreplay (e.g., kissing, caressing, manual, or oral genital stimulation) 3. Coitus? Positions used? 4. Verbalization during sex? If so, what kind? 5. Afterplay ? (whether sex act is completed or disrupted by dysfunction); typical activities (e.g., holding, talking, return to daily activities, sleeping) 6. Feeling after sex: relaxed, tense, angry, loving H. Sexual compulsivity ? (intrusion of sexual thoughts or participation in sexual activities to a degree that interferes with relationships or work, requires deception, and may endanger the pt.

18. III. Past sexual history A. Childhood sexuality 1. Parental attitudes about sex 2. Parents’ attitudes about nudity and modesty 3. Learning about sex a. From parents b. From books, magazines, or friends at school or through religious group? c. Significant misinformation d. Feeling about information e. Viewing or hearing primal scene—Reaction? 4. Viewing sex play or intercourse of person other than parent 5. Viewing sex between pets or other animals

19. B. Childhood sex activities 1. Genital self-stimulation before adolescence—Age? Reaction if apprehended? 2. Awareness of self as boy or girl 3. Sexual play or exploration with another child ? I. Adolescence A. Age of onset of puberty B. Sense of self as feminine or masculine C. Sex activities 1. Masturbation 2. Homosexual activities 3. Dating 4. Experiences of kissing, necking, petting 5. Orgasm 6. First coitus

20. II. Adult sexual activities A. Premarital sex 1. Types of sex play experiences 2. Contraception and/or safe sex precautions used 3. First coitus (if not experienced in adolescence) 4. Cohabitation 5. Engagement B. Marriage 1. Types and frequency of sexual interaction-Satisfaction with sex life? View of partner’s feeling. 2. First sexual experience with spouse 3. Honeymoon 4. Effect of pregnancies and children on marital sex 5. Extramarital sex 6. Post marital masturbation—Frequency? Effect on marital sex? 7. Extramarital sex by partner—effect on interviewee 8. Ménage à trois or multiple sex (swinging) ( polyamony ) 9. Areas of conflict in marriage (e.g., parenting, finances, division of responsibilities, priorities)

21. III. Sex after widowhood, separation, divorce —celibacy, orgasms in sleep, masturbation, noncoital sexplay , intercourse IV. Special issues A. History of rape, incest, sexual, or physical abuse B. Spousal abuse (current) C. Chronic illness (physical or psychiatric) D. History or presence of sexually transmitted diseases E. Fertility problems F. Abortions, miscarriages, or unwanted or illegitimate pregnancies G. Gender identity conflict—(e.g., transsexualism, wearing clothes of opposite sex) H. Paraphilias—(e.g., fetishes, voyeurism, sadomasochism)

22. Sexual dysfunctions Essential features of sexual dysfunctions - inhibition, specifically, an inability to respond to sexual stimulation physiologically or psychologically ,or the experience of pain during the sexual act. Dysfunction- disturbance in the subjective sense of pleasure usually associated with sex, or by the objective performance. Acc to ICD-10, sexual dysfunction - person’s inability “to participate in a sexual relationship as he or she would wish.” The dysfunction is expressed as a lack of desire or of pleasure or as a physiological inability to begin, maintain, or complete sexual interaction

23. Male Hypoactive Sexual Desire Disorder(302.71/F52.0)

24. Male Hypoactive Sexual Desire Disorder(302.71/F52.0) Prevalence of low desire in men reported as 2% in 26-44yrs;6% in 18-24yrs;40% in 66-74yrs. Causative factors- Freud conceptualization-result of inhibition during phallic psychosexual phase& of unresolved oedipal conflicts.-vagina dentata. Chronic stress, anxiety, depression. Desire depends on several factors: biological drive,adequate self-esteem, previous good experiences with sex, the availability of an appropriate partner, and a good relationship in nonsexual areas with one’s partner. Damage to any of those factors may result in diminished desire. Hypoactive sexual desire disorders often become manifest during puberty and may be a lifelong condition.

25. Female Sexual Interest/Arousal Disorder(302.72/F52.22) A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following: 1. Absent/reduced interest in sexual activity. 2. Absent/reduced sexual/erotic thoughts or fantasies. 3. No/reduced initiation of sexual activity, & typically unreceptive to a partner’s attempts to initiate. 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approx. 75–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual). 6. Absent/reduced genital or non genital sensations during sexual activity in almost all or all (approximately 75–100%) sexual encounters (in identified situational contexts or, if generalized, in all contexts). B. The symptoms in criterion A have persisted for a minimum duration of approximately 6 months . C. The symptoms in criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

26. Specify whether : Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexual function. Specify whether : Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners. Specify current severity : Mild : Evidence of mild distress over the symptoms in criterion A. Moderate : Evidence of moderate distress over the symptoms in criterion A. Severe : Evidence of severe or extreme distress over the symptoms in criterion A. Female Sexual Interest/Arousal Disorder(302.72/F52.22)

27. Women do not necessarily move stepwise from desire to arousal. A complicating factor in this diagnosis is that a subjective sense of arousal is often poorly correlated with genital lubrication in both normal and dysfunctional women. Therefore, complaints of lack of pleasure are sufficient for these diagnoses even when vaginal lubrication and congestion are present. Factors such as life stresses, aging, menopause, presence of adequate sexual stimulation, must be evaluated before making this diagnosis. Relationship problems are particularly relevant to acquired interest/arousal disorder. Female Sexual Interest/Arousal Disorder(302.72/F52.22)

28. Erectile Disorder(302.72/F52.21) A. At least one of the three following symptoms must be experienced on almost all or all(approx. 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): 1. Marked difficulty in obtaining an erection during sexual activity. 2. Marked difficulty in maintaining an erection until the completion of sexual activity. 3. Marked decrease in erectile rigidity. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months . C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

29. Specify whether : Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexual function. Specify whether : Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners. Erectile Disorder(302.72/F52.21)

30. Historically – impotence - feelings of powerlessness,helplessness ,& resultant low self-esteem. Acquired male erectile disorder reported in 10-20% of all men. Life long disorder is rare. It can be organic or psychological or combination. In young & middle age usually it is psychological. Madonna putana complex Punitive super ego, inability to trust, feeling of inadequacy as a partner. Erectile Disorder(302.72/F52.21)

31. Female Orgasmic Disorder(302.73/F52.31) A. Presence of either of the following symptoms and experienced on almost all or all (approx.75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts): 1. Marked delay in, marked infrequency of, or absence of orgasm. 2. Markedly reduced intensity of orgasmic sensations. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months . C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

32. Specify whether : Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexual function. Specify whether : Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners. Specify if: Never experienced an orgasm under any situation. Specify current severity : Mild : Evidence of mild distress over the symptoms in Criterion A. Moderate : Evidence of moderate distress over the symptoms in Criterion A. Severe : Evidence of severe or extreme distress over the symptoms in Criterion A. Female Orgasmic Disorder(302.73/F52.31)

33. Incidence of never having experienced orgasm is 10% among all women. Lifelong female orgasmic disorder- more common in unmarried. Increased orgasmic potential in women >35yrs- explained on basis of less psychological inhibition, greater experience or both. fears of impregnation, rejection by a sex partner, & damage to the vagina; hostility toward men; poor body image & feelings of guilt about sexual impulses are associated with female orgasmic disorder. Prolonged marital discord may lead to anorgasmia. Female Orgasmic Disorder(302.73/F52.31)

34. Delayed Ejaculation(302.74/F52.32) A. Either of the following symptoms must be experienced on almost all or all occasions (approx. 75%-100%) of partnered sexual activity (in identified situational contexts or, if generalized, in all contexts), and without the individual desiring delay: 1. Marked delay in ejaculation. 2. Marked infrequency or absence of ejaculation. B. The symptoms in Criterion A have persisted for a minimum duration of approximately 6 months . C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

35. Specify whether : Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexul function. Specify whether : Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners. Specify current severity : Mild : Evidence of mild distress over the symptoms in Criterion A. Moderate : Evidence of moderate distress over the symptoms in Criterion A. Severe : Evidence of severe or extreme distress over the symptoms in Criterion A. Delayed Ejaculation(302.74/F52.32)

36. Retarded ejaculation- achieves ejaculation during coitus with great difficulty, if at all. It is sometimes present with masturbation but appears as a problem primarily during partnered sex. A general prevalence of 5 % has been reported. However, an increase is noted in sex therapy programs-has been attributed to the increasing use of antidepressants ( have side effect -delayed ejaculation) & high use of Internet pornography sites. Lifelong delayed ejaculation- indicates severe psychopathology. A man may come from a rigid, puritanical background. In an ongoing relationship, acquired male delayed ejaculation disorder frequently reflects interpersonal difficulties, unexpressed hostility toward a woman. It is more common among men with OCD than among others. Delayed Ejaculation(302.74/F52.32)

37. Premature (Early) Ejaculation(302.75/F52.4) A. A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. Note : Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities. B. The symptom in Criterion A must have been present for at least 6 months and must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity (in identified situational contexts or, if generalized, in all contexts). C. The symptom in Criterion A causes clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

38. Specify whether ; Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexual function. Specify whether : Generalized : Not limited to certain types of stimulation, situations, or partners. Situational : Only occurs with certain types of stimulation, situations, or partners. Specify current severity : Mild : Ejaculation occurring within approximately 30 seconds to 1 minute of vaginal penetration. Moderate : Ejaculation occurring within approximately 15-30 seconds of vaginal penetration. Severe : Ejaculation occurring prior to sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration. Premature (Early) Ejaculation(302.75/F52.4)

39. Clinicians need to consider factors that affect the duration of the excitement phase of the sexual response, such as age, the novelty of the sex partner, and the frequency and duration of coitus. Difficulty in ejaculatory control -associated with anxiety regarding the sex act, with unconscious fears about vagina, or with negative cultural conditioning. Men whose early sexual contacts -largely with prostitutes, or whose sexual contacts took place in embarrassing situations , might have been conditioned to achieve orgasm rapidly. With young, inexperienced men, who have the problem, it may resolve in time. In ongoing relationships-a stressful marriage exacerbates the disorder. The developmental background and the psychodynamics found in premature ejaculation and in erectile disorder are similar. Premature (Early) Ejaculation(302.75/F52.4)

40. Genlto-Pelvic Pain/Penetration Disorder(302.76/F52.6) A. Persistent or recurrent difficulties with one (or more) of the following: 1. Vaginal penetration during intercourse. 2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts. 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration. 4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration. B. The symptoms in Criterion A have persisted for a min.duration of approx . 6 mon . C. The symptoms in Criterion A cause clinically significant distress in the individual. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

41. Specify whether : Lifelong : The disturbance has been present since the individual became sexually active. Acquired : The disturbance began after a period of relatively normal sexual function. Specify current severity : Mild : Evidence of mild distress over the symptoms in Criterion A. Moderate : Evidence of moderate distress over the symptoms in Criterion A. Severe : Evidence of severe or extreme distress over the symptoms in Criterion A. Genlto-Pelvic Pain/Penetration Disorder(302.76/F52.6)

42. Chronic pelvic pain is a common - in women with a history of rape or childhood sexual abuse; from tension and anxiety about the sex act; partner proceeding with intercourse regardless of a woman’s state of readiness, the condition is aggravated. Increase in reported dyspareunia -post menopausally due to hormonally induced physiologic changes in the vagina; immediate postpartum population, but, it is usually temporary. Dyspareunia in men, -uncommon; usually associated with a medical condition- Peyronie disease, prostatitis, or gonorrheal or herpetic infections; may be due to psychological conflicts about the sex act or an adverse effect of some antidepressant medications. Genlto-Pelvic Pain/Penetration Disorder(302.76/F52.6)

43. Substance/Medication-Induced Sexual Dysfunction A. A clinically significant disturbance in sexual function is predominant in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2): 1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. 2. The involved substance/medication is capable of producing the symptoms in Criterion A. C. The disturbance is not better explained by a sexual dysfunction that is not substance/ medication-induced. Such evidence of an independent sexual dysfunction could include the following: The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced sexual dysfunction (e.g., a history of recurrent non-substance/medication-related episodes). D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress in the individual.

44. Substance/Medication-Induced Sexual Dysfunction Note : This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention. Specify if : With onset during intoxication : If the criteria are met for intoxication with the substance and the symptoms develop during intoxication. With onset during withdrawal : If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal. With onset after medication use : Symptoms may appear either at initiation of medication or after a modification or change in use. Specify current severity : Mild : Occurs on 25%-50% of occasions of sexual activity. Moderate : Occurs on 50%-75% of occasions of sexual activity. Severe : Occurs on 75% or more of occasions of sexual activity

45. Nutritional disorders Malnutrition Vitamine déficiences Infectious and parasitic diseases Elephantiasis Mumps Cardiovascular disease Atherosclerotic disease Aortic aneurysm Leriche syndrome Cardiac failure Renal and urological disorders Peyronie disease Chronic renal failure Hydrocele and varicocele Hepatic disorders Cirrhosis (usually associated with ADS) Genetic disorders Klinefelter syndrome Congenital penile vascular and structural abnormalities Endocrine disorders Diabetes mellitus Dysfunction of the pituitary–adrenal–testis axis Acromegaly Addison disease Chromophobe adenoma Adrenal neoplasia Myxedema Hyperthyroidism Pulmonary disorders Respiratory failure Neurological disorders Multiple sclerosis Transverse myelitis Parkinson disease Temporal lobe epilepsy Traumatic and neoplastic spinal cord diseases Central nervous system tumor Amyotrophic lateral sclerosis Peripheral neuropathy General paresis Tabes dorsalis Poisoning Lead Herbicides Surgical procedures Perineal prostatectomy Abdominal–perineal colon resection Sympathectomy (frequently interferes with ejaculation) Aortoiliac surgery Radical cystectomy Retroperitoneal lymphadenectomy Miscellaneous Radiation therapy Pelvic fracture Any severe systemic disease or debilitating condition Pharmacological contributants Alcohol, tobacco and other dependence-inducing substances (heroin, methadone, morphine, cocaine, amphetamines, and barbiturates) Prescribed drugs (psychotropic drugs, antihypertensive drugs, estrogens , and antiandrogens) Sexual dysfunction due to a general medical condition

46. The mechanisms involved in the various diseases that lead to erectile disorder include; general endothelial dysfunction or dysfunction of the penile endothelium specifically, atherosclerosis, dysregulation of nitric oxide synthase, decrease of nitric oxide, low testosterone levels due to hyperprolactinemia-influenced changes in the hypothalamic–pituitary axis, vasculopathy, autonomic neuropathy, disruption of neural pro erectile processes. Substance/Medication-induced Sexual dysfunction

47. Pharmacological agents implicated in sexual dysfunction Antipsychotics-CPZ, trifluperazine -impair erection & ejaculation. Antidepressants α-Adrenergic and β-adrenergic receptor antagonists Anticholinergics Antihistamines: diphenhydramine, cyproheptadine Antianxiety agents-improve sexual function by diminishing anxiety by decreasing plasma epinephrine concentration. Alcohol ,opioids, hallucinogens, cannabis Barbiturates and similar acting drugs

48. Other Specified Sexual Dysfunction (302.79/F52.8) Unspecified Sexual Dysfunction (302.70/F52.9)

49. references Sadock BJ, Sadock VA, Ruiz P. 21.1. In: Kaplan and Sadock's comprehensive textbook of psychiatry. Philadelphia: Wolters Kluwer.; 2017. Sadock BJ, Sadock VA, Ruiz P. 17 In: Kaplan and Sadock's synopsis of psychiatry: Behavioural Sciences/Clinical Psychiatry. 11th ed. Philadelphia: Wolter Kluwer; 2015. p. 1217–59. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

50. Thank you