Sexual Health and Development Across the Lifespan I&II - Lec. 14&15 - Singer - Human Sexuality

What's A Normal Sex Life Anyway

"Normal" Female Sexuality Defined by Cultural Norms Historically given little attention Victorian era: discovery that female orgasm is irrelevant to conception Women's sexuality hits "Primetime," but not quite its "Prime"

Neurobiology of the Sexual Response Cycle

**Excitatory factors include**: Sex steroids: estrogen and testosterone Neurotransmitters: *dopamine, norepinephrine (NE)*, melanocortin and oxytocin Dopamine modulates sexual desire NE and dopamine increase sense of sexual excitement and desire to continue sexual activity1 **Inhibitory factors include**: *Serotonin*, prolactin and endogenous opioids Neurotransmitters modulate the secretion of many horomones Hormones influence synthesis and storage of neurotransmitters2

SEXUALity begins before birth and lasts a lifetime

*Infants and toddlers (ages 0-2)* Males can have erections in the uterus and females are capable of vaginal lubrication from birth Masturbation: Normal, done because it provides pleasure, indicates exploration of the body. Boys and girls can experience orgasm although boys will not ejaculate until puberty. By about age two, children know their own gender. They are aware of differences in the genitals of males and females and in how males and females urinate. *Early childhood (ages 2-6)* Physical Development Crucial period for physical development from walking to talking Learn about nature of their bodies Psychosexual Development Toilet training leads to an intense interest in genitals and bodily functions Children begin to ask basic questions about sexuality Children are exploring what it means to be "boys" or "girls" Sexual Behavior Masturbation may be deliberate and obvious Parental reaction is important - setting socially acceptable limits while supporting developmentally driven exploration Childhood sex play often begins - exposing genitals, touching

Specific Laboratory and Other Tests

*Men*: AM serum testosterone Especially if symptoms of hypogonadism: decreased libido, decreased energy, fatigue If low AM testosterone Repeat AM testosterone LH/FSH Prolactin *Women*: Measurement of testosterone levels controversial Most recommendations are against checking levels for diagnostic purposes Other tests - rarely needed (ED) Nocturnal tumescence testing (Rigiscan): psychologic ED Vascular studies: Penile Dynamic Duplex Doppler study

Gender Journey (Ehrensaft)

1.Genetic Gender: chromosomal inheritance be it XX, XY, or other 2.Physical Gender: primary and secondary sexual characteristics - penis and testicles, or vagina, ovaries, and uterus 3.Brain Gender: or functional structures of the brain along gender lines Core gender identity is the psychological core sense of self as male or female (or other) Gender is an interweaving of nature and nurture Child is a moving target and gender development is a lifelong process Follow the child's lead and go where the child takes you Listen and respond, rather than guide, enforce or force There is no one healthy gender outcome

Myth: Safer Sex Practices are More Essential for Youth Than for Seniors

10-15% of newly diagnosed HIV is among those age 50 and older (40,000/year). Doctors don't ask Seniors don't tell Women are more susceptible due to the vagina being more permeable Immune system compromised due to aging Seniors associate condoms with contraception and do not use them regularly to prevent STIs Must consider every previous partner ever slept with and all of their partners

Sexuality and Health Among Older AdultsNational Social Life, Health, and Aging Project

3005 U.S. adults, aged 57-85 (1550 women, 1455 men) Many are sexually active Women are less likely than men to have a spousal/ intimate relationship and to be sexually active Sexual activity strongly linked to overall health in both men and women ~ 50% of women and men reported at least one bothersome sexual problem. In women: Low desire 43% Difficulty with vaginal lubrication 39% Inability to reach orgasm 34% Sex not pleasurable 23% Sexual problems are infrequently discussed with physicians

Key Concepts

A minority of people, especially women, seek help for sexual problems Long‐term sexual problems are associated with loss of well‐being, relationship dissatisfaction and diminished health‐related, quality of life (HQL). Unmet medical need is persistent and noteworthy: Sexual problems in general are under‐recognized and under‐treated.

Management: GPPPD

Pain with penetration Pelvic floor physical therapy -mainstay of treatment Uses biofeedback Tensing/tightening of pelvic floor muscles Progressive muscle relaxation and vaginal dilatation Success rates approach 90% Refer non-responders to sex therapists (sooner rather than later) Review experiences Abuse Compensatory/Defense mechanisms

When to Consider Referral to a Specialist

Sexual problems have occurred as a result of trauma Sexual problems have been chronic ("I've always had this problem") Underlying medical or psychiatric problem and treatment are beyond the scope of your practice You are uncomfortable working with the client or the situation Lack of response/treatment failure Specialized diagnostic evaluation necessary Patients with significant Peyronie's Disease or other penile deformity

Most Men and Women Rate Sex as Important in Their Overall Life

Speaker's notes: This global survey assessed the importance of sexuality and intimacy in 26,000 men and women aged 40 to 80 years in 29 countries. Surveys were completed by telephone or face-to-face interview and results are based on a 5-point scale where 5 is extremely important and 1 is not at all important. The survey suggests that sex remains an important aspect of life for the majority of adults.

Cognitive Development Theory (Kohlberg)

Stage theory of gender development As child moves forward through stages, understanding becomes more complex Information about gender is gathered from the environment *Gender Identity/Labeling* ~age 2 Child is able to correctly label own gender *Gender Stability* ~age 3-5 Gender remains the same across time *Gender Consistency* ~age 6 Gender is independent of external features

Categories of Sexual Dysfunction: DSM-5

Symptoms persist > 6 months and not better explained by a nonsexual mental disorder or consequence of severe relationship distress or other significant stressors and not due to effects of substance/medication or other medical condition

Hormonal Therapy in Men

Testosterone replacement therapy May be effective in HSDD and in a small fraction of ED patients with documented hypogonadism Parenteral (IM and IM depot), transdermal (patches, gels), and SQ implantable pellet preparations available Exogenous testosterone caveats Can suppress remaining endogenous androgen production --> spermatogenesis is severely suppressed May be metabolized to estradiol with potentially detrimental effects on sexual function Can adversely affect lipid profile May increase risk of cardiovascular events May increase risk of prostate hypertrophy and cancer

No FDA Approved Testosterone Options for Desire Disorders in Women

Testosterone transdermal patches Testosterone gels and patches approved for men Compounded 1% testosterone cream or gel for women Oral methyltestosterone (MT) Testosterone enanthate injections Subcutaneous pellets Sublingual testosterone

Evaluating Sexual Function

ASK and LISTEN ! You cannot treat a problem if you don't know it exists Screening sexual history can be incorporated into medical interview where the clinician finds it appropriate and when the questions arise naturally Opportunities include: During gynecological review of systems During social history

Transurethral suppositoryMUSE (alprostadil)

Advantage Relatively non-invasive Works within 15-30 minutes Disadvantages Expensive (~$40) Needs refrigeration Penis pain (up to 50%) 50% success rate Burning with urination Vaginal pain Penile Implants Ideal for men with moderate to severe ED, who have tried other treatments without success Single 1" incision 60 minute operation Overnight stay 1-2 weeks of recovery time Advantages Very effective (~90% success) Allows for spontaneity - have sex when the mood strikes Firm and dependable erection Maintain erection as long as one wants Cost-effective High patient and partner satisfaction Disadvantage Requires an operation Erect penile length shorter than natural erection

The Role of Androgens

Androgens appear to be important in both male and female sexuality Decline in androgens parallels increasing age in late reproductive years (30+ for women, later for men) Declining levels can contribute to decline in sexual desire, arousal, and orgasm

**So What's Normal?**

Normal is what feels good physically and is emotionally satisfying! Determinants of healthy sexual functioning: - Physical/psychological health - Relationship with partner Developmental experiences - Adequate education and information Educational level Lifestyle factors - Rest, exercise

After you have asked the mother to "please step out," Michelle confides in you that she has had unprotected sex and thinks she might be pregnant.

Can she consent to a pregnancy test without the consent of a parent? Age of majority- 18 years (most states) State Specific Laws www.guttmacher.org www.cahl.org Minor has the same capacity to consent for care as an adult for: Treatment, diagnosis and counseling for an STI Treatment, diagnosis, and counseling for pregnancy and contraception Treatment and counseling for alcohol or drug use Examination and treatment for rape or sexual offense

Older adults

Changes in Sexuality with Age Developmental Changes Illness, Surgery, Medication Lifestyle changes Loss of or lack of partner New Relationships Discovery and re-discovery Living Environment

Sex Tips for Older Adults

Communication Use of lubricants Sexual positions - "on the side" Explore other sexual activities Timing of sex Increased stimulation

Middle Adolescent Sexual Development (15-17)

Dating and petting are common *Initiation of sexual activity with both non-coital and coital contact* Denial of consequences of sexual behavior is typical Stronger sense of identity Relates more strongly to peer group More reflective thought Awareness of sexuality

Prevalence of FSD: PRESIDE

OBJECTIVES: Estimate the prevalence of self-reported sexual problems (any, desire, arousal, and orgasm), the prevalence of problems accompanied by personal distress, and describe related correlates NOT DETERMINED: Whether low desire with sexually related personal distress was primary or secondary to another illness; pain was not assessed POPULATION: 31,581 US female respondents ≥18 years of age from 50,002 households RESULTS*: Response rate was 63% (n=31,581 / 50,002)

Michelle is a 15-year-old woman who has come to your clinic with her mother complaining of an ear infection. Her mother requests to remain in the room for the exam.

Explain to the mother that though you commend her for her interest in her daughter's health care, in your office, a patient's confidentiality must be assured. Invite the mother to wait outside in the waiting room until you have finished interviewing her daughter. Teens wait approximately 2 years after first sexual activity before visiting a clinician Major concern is lack of confidentiality

Gender Schema Theory (Bem)

Explains how individuals become gendered in a society Once children form a basic gender identity they start to develop gender schemas Gender Schema - an organized set of gender related beliefs that influence behaviors Explains some of the process by which gender stereotypes become so psychologically ingrained in our society

Common Immediate Causes of Sexual Dysfunction

Fatigue - most common cause Insufficient stimulation A stranger to pleasure Negative thinking / anti-fantasy/ loss of the erotic focus Explicit anger - "not in the mood"

Female Orgasmic Disorder

Female orgasmic disorder Delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress Primary (lifelong) - 1 in 10 women Fear of losing control or being vulnerable Prior deliberate curtailing of high arousal Lack of trust of others, Fear of intimacy Secondary (acquired) Medication associated (SSRIs, alcohol, sedatives) Neurologic diseases, autonomic nerve damage >40% of women are "situationally orgasmic"

Second Lecture Objectives

Following this presentation, the participant should be able to: Describe the epidemiology of male and female sexual disorders with a focus on the most common disorders: erectile dysfunction in men and hypoactive sexual desire disorder (HSDD) in women. Define the sexual disorders, and identify barriers to appropriate assessment and diagnosis. List common causes of sexual dysfunction Describe the clinical evaluation of the patient with sexual dysfunction. Describe common medical, behavioral, and psychological interventions and outline management strategies for the treatment of male and female sexual problems

Late Adolescent Sexual Development (18+)

Full physical and socio-legal maturation Sexual behavior becomes more expressive and less exploitative Focus on intimacy and formation of stable relationships Distinct identity; ideas and opinions become more settled Plans for future and commitments

Female Sexual Interest/Arousal Disorder (3 of the six)

Lack of, or significantly reduced, sexual interest/arousal as manifested by 3 of Absent/reduced interest in sexual activity Absent/reduced sexual/erotic thoughts or fantasies No/reduced initiation of sexual activity and unreceptive to partner's attempts to initiate Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (75-100%) sexual encounters Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (written, verbal, visual) Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (75-100%) sexual encounters Symptoms persisted a minimum of 6 months and not better explained by a nonsexual mental disorder or consequence of severe relationship distress or other significant stressors and not due to effects of substance/medication or other medical condition

DSM 5 Specifiers

Lifelong vs. Acquired Generalized vs. Situational Severity: Mild, Moderate, Severe Other considerations: Marked Personal Distress Marked Interpersonal Difficulty Explanatory Factors: age, context of the person's life, adequacy of stimulation, etc

Role of the Clinician

Listen and Clarify Intervene to the Extent that You are Comfortable and Skilled Refer as Necessary to Appropriate Providers Keep the Door Open

Pre-adolescent Sexual Development

Low physical and mental investment in sexuality Many questions and collecting of information about sexuality from friends, school, and family Puberty begins (ages 9-12) though physical appearance is pre-pubertal/varies More self-conscious about their bodies Masturbation increases during these years. Same-gender sexual behavior and exploration common. Such behavior is unrelated to a child's sexual orientation. Group dating, sexual play, sex games - spin the bottle, truth or dare, etc. Concrete thinking

Mechanism of Erection: Cross Section

Mechanism of Erections: Cross Section The 2 structural compartments of the penis, the paired corpora cavernosa and the corpus spongiosum, are interspersed with a complex network of endothelial cell-lined lacunae, helicine arteries, and nerve terminals. The organ is innervated by somatic and autonomic nerve fibers.1 The tunica albuginea is the dense, fibrous, elastic covering of the corpora cavernosa in the penis. During an erection, small penile blood vessels are compressed against the tunica albuginea, trapping blood in the penis and causing it to stay rigid.1 Achieving an erection is a complex process. In a flaccid penis, there is a balance between blood flow in and out of the erection chambers. When a man becomes aroused, blood flow to the penis increases significantly. As the penis expands and hardens, veins that normally carry blood away from the penis are compressed. This limits the amount of blood that can flow out of the penis. With more blood flowing in and less blood flowing out, the penis enlarges and becomes fully erect.2

PDE5 Inhibitors: Onset, Half-Life, and Duration of PDE5 Inhibitors

Nitrates: absolute contraindication

Treatment of PE

Pause-squeeze technique: Begin sexual activity as usual, including stimulation of the penis, until you feel almost ready to ejaculate. Have your partner squeeze the end of your penis, at the point where the head (glans) joins the shaft, and maintain the squeeze for several seconds, until the urge to ejaculate passes. Have your partner repeat the squeeze process as necessary. By repeating as many times as necessary, you can reach the point of entering your partner without ejaculating. After some practice sessions, the feeling of knowing how to delay ejaculation might become a habit that no longer requires the pause-squeeze technique. If the pause-squeeze technique causes pain or discomfort, another technique is to stop sexual stimulation just prior to ejaculation, wait until the level of arousal has diminished and then start again. This approach is known as the stop-start technique. Condoms - used to decrease penis sensitivity Topical anesthetics: Apply 10-15 minutes before sex to reduce sensation and help delay ejaculation Potential side effects - temporary loss of sensitivity, decreased sexual pleasure, female partners can have same side effects

External Barriers to Care

Perceived lack of confidentiality and restrictions (parental consent/notification) Poor communication by providers Lack of provider knowledge and skills Lack of money, insurance, and transportation Inaccessible locations and/or limited services Limited office hours

Intervention and Treatment: Office Based Counseling for Sexual Problems: *PLISSIT Model*

Permission to talk about sexual issues, reassurance and empathy Limited Information e.g., education about genital anatomy or educational resources Specific Suggestions e.g., use of lubricants, altering position Intensive Therapy e.g., referral for psychotherapy/sex therapy

(Male) Hypoactive Sexual Desire Disorder (HSDD)

Persistent or recurrent deficiency (or absent) sexual/erotic thoughts or fantasies and/or desire for sexual activity Causes marked personal distress or interpersonal difficulties Symptoms persist > 6 months and not better explained by a nonsexual mental disorder or consequence of severe relationship distress or other significant stressors and not due to effects of substance/medication or other medical condition In men: May be first sign of clinical depression May be reaction to poor erectile performance

Female Sexual Arousal Disorder

Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement Subtypes Generalized arousal disorder - no subjective or genital arousal Genital arousal disorder - genital engorgement present but not attended to "Missed" arousal - subjective excitement is present but genital engorgement is absent

Early Adolescent Sexual Development (~11-14)

Physical maturation starts Growth spurt Extreme concern and curiosity about their comparison to peers Sexual fantasies are common and may be source of guilt Increased interest in sexual anatomy Self-exploration and evaluation Begin to think abstractly Limited dating and intimacy

Ejaculatory Dysfunction

Premature Ejaculation Absent or delayed ejaculation Retrograde ejaculation Lifelong PE: Ejaculation that always or nearly always occurs prior to or within about 1 minute of vaginal penetration (lifelong PE) (ISSM definition) Acquired PE: Clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (ISSM definition) PE: Within approximately 1 minute following vaginal penetration (DSM-5) Inability to delay ejaculation on all or nearly all vaginal penetrations. Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy. Exact etiology is unknown Biological and psychological hypotheses Anxiety, penile hypersensitivity, and 5-HT receptor dysfunction

Common Psychosocial Causes of Sexual Dysfunction

Relationship conflict Communication problems Major life stressor(s) Lack of attraction Boredom Discrepant desire levels between partners Cultural/religious prohibitions/guilt Subclinical depression/anxiety/body image

**Flibanserin**

Serotonin may have a role in HSDD by acting as a sexual satiety signal SSRIs inhibit desire, arousal, and orgasm 5HT1-agonist/5HT2A-antagonist --> prosexual effects >11,000 subjects studied SE: mild nausea, dizziness, fatigue, somnolence, increased bleeding if on NSAID or ASA Indication: Treatment of premenopausal women with acquired, generalized HSDD as characterized by low sexual desire that causes marked distress or interpersonal difficulty and is NOT due to:- A co-existing medical or psychiatric condition,- Problems within the relationship, or- The effects of a medication or other drug substance. Acquired HSDD refers to HSDD that develops in a patient who previously had no problems with sexual desire. Generalized HSDD refers to HSDD that occurs regardless of the type of stimulation, situation, or partner. WARNING: HYPOTENSION AND SYNCOPE IN CERTAIN SETTINGS

Types of Interventions

Sex Counseling/Therapy Psychotherapy with a chief complaint of a sexual problem Although the stated goal is to correct a sexual problem, sex therapy often does not focus solely on sexual function Sexuality is best understood within a biopsychosocial model and treatment follows that model Physical therapy Pharmacologic therapies Adjunctive and alternative therapies Patient education Male or female anatomy Role of hormones, effects of aging and menopause on sexuality Bibliotherapy Redefine "normal" sexual activity Alter sexual behaviors that are no longer possible or satisfying Expand sexual behavior repertoire Improve communication between partners

Human Sexual Response Cycle: Classic Linear Model

Sex response is a natural phenomenon in which sensory stimulation leads to increased peripheral blood flow and vasocongestion Genital tissues and breasts are most obviously affected With continuing stimulation, there is a build-up of muscle tension and the development of a "plateau" phase that leads to orgasm During orgasm, there is widespread muscle contraction and increased cardiac output Resolution follows orgasm with return to the unstimulated state The essential components of sex response depend upon adequate functioning of nerves, arteries, and muscles Blue is the traditional normal model

Evaluation

Sexual History Onset: sudden or gradual Duration: recent or lifelong Generalized or Partner/situation specific Pain ED Specific History Difficulty getting an erection Difficulty maintaining erection Ability to penetrate Strength of erection (1-10) AM erections, frequency Curvature Physical Exam Cardiovascular exam Neurologic exam Secondary sex characteristics Gynecologic exam (external and internal) or penile/scrotal exam Laboratory tests Complete blood count Comprehensive metabolic panel Hemoglobin A1C Lipid profile TSH/thyroid tests PSA (men)

Male Genital Arousal:Physiology of Erection **"Point and Shoot"**

Understand the difference between parasympathetic and sympathetic point = parasympathetic shoot = sympathetic

NSSHB: Sexual Repertoire

Vaginal intercourse most common in all age groups Oral sex - past year 58% ages 18-59 16% ages 60+ Anal sex - past year 17% ages 18-59 3% ages 60+ Masturbation - past month 62% of men ages 18-59; 35% of men age 60+ 38% of women ages 18-59; 17% of women age 60+ Sex materials (erotic magazines, films, toys) 41% of men 16% of women

The Impact of Sexual Dysfunction on a Relationship

When sex is good: It adds 15-20% additional value to a relationship When sex is bad/non-existent: It plays an inordinately powerful role draining the relationship of all positive value, about 50-70%!

High schoolers

lots of sex.

Components of Desire

motivation rules the day Refocus on motivation component of desire Alter expectations that response is linear Sexual neutrality/responsive desire Cognitive and behavioral restructuring of perceptions of partner and lovemaking Sensate-focus exercises/sensual massage Enhance erotic focus Encourage development of sexual fantasies Male vs. Female-centered erotica Counteract drug effects (adjust dose, substitute meds, add an antidote) Consider androgen therapy Consider flibanserin

(Female) Sexual Response Cycle: Non-linear (Circular) or Intimacy Based Model of Sexual Functioning

orgasm is not listed here - does not have to be a part of it though it often is. Female Sexual Response Cycle And now Rosemary Basson offers an alternative model to understanding the sexual response cycle that suggests that for women, it is not so linear and that for many women, desire comes after arousal and that many women begin from a point of sexual neutrality. Arousal may come from a conscious decision or as a result of seduction or suggestion from a partner. This is extremely important to understand because you can then normalize this reality for your patients who have come to believe that because the initial drive has gone they are no longer sexual beings and to reassure their partners that it is not that they have lost desirability. (e.g analogy of going to the gym—) So, Sexual neutrality or being receptive to rather than initiating sexual activity is considered a normal variation of female sexual functioning. This is very important for you to keep in mind as I review the female sexual dysfunctions, particularly hypoactive sexual desire disorder. This slide graphically illustrates "normal" female sexual response. Women's desire has a large responsive (receptive) component that is driven by intimacy and is circular in nature. When any one (or more than one) aspect or phase of the cycle is absent, the patient may experience one or more sexual dysfunctions. Satisfaction is an essential component of the sexual response cycle. Instead of a linear relationship with orgasm as the end point, a cyclic concept with satisfaction as the focus appears to be more appropriate in females. The cycle: A woman starts out desire-neutral. If the patient experiences adequate emotional intimacy with her partner, she may seek or be receptive to sexual stimuli. Receptivity to sexual stimuli allows the woman to move from sexual neutrality to arousal. If the mind continues to process the stimuli on to further arousal, sexual desire will encourage the woman to move forward to sexual satisfaction and orgasm. This positive outcome fosters intimacy and reinforces sexual motivation. Non-linear Model Basson has also constructed a new model of female sexual response that incorporates the importance of emotional intimacy, sexual stimuli, and relationship satisfaction (see Figure 3).6 This model acknowledges that female sexual functioning proceeds in a more complex and circuitous manner than male sexual functioning and that female functioning is dramatically and significantly affected by numerous psychosocial issues (e.g., satisfaction with the relationship, self-image, previous negative sexual experiences). According to Basson, women have many reasons for engaging in sexual activity other than sexual hunger or drive, as the traditional model suggests. Although many women may experience spontaneous desire and interest while in the throes of a new sexual relationship or after a long separation from a partner, most women in long-term relationships do not frequently think of sex or experience spontaneous hunger for sexual activity. In these latter cases, Basson suggests that a desire for increased emotional closeness and intimacy or overtures from a partner may predispose a woman to participate in sexual activity. From this point of sexual neutrality—where a woman is receptive to being sexual but does not initiate sexual activity—the desire for intimacy prompts her to seek ways to become sexually aroused via conversation, music, reading or viewing erotic materials, or direct stimulation. Once she is aroused, sexual desire emerges and motivates her to continue the activity. On the road to satisfaction, there are many points of vulnerability that may derail or distract a woman from feeling sexually fulfilled. The Basson model clarifies that the goal of sexual activity for women is not necessarily orgasm but rather personal satisfaction, which can manifest as physical satisfaction (orgasm) and/or emotional satisfaction (a feeling of intimacy and connection with a partner).6,8