Repro test 3 combined* ppts 1-3

Human Sexual Response Phases

• Masters and Johnson outlined four phases: Excitation, Plateau, Orgasm, Resolution
• Two main processes drive response: Vasocongestion (blood flow increase) and Myotonia (muscle tension)

Excitation Phase

• Vasocongestion is prominent, especially in the pelvis
• Males: Penis becomes erect, scrotum thickens and elevates
• Females: Lubrication, clitoral enlargement, nipple erection (myotonia), breast enlargement, labia minora swelling and darkening, vaginal ballooning, cervix and uterus tenting
• Both Sexes: "Sexual flush" due to skin vasocongestion, increased heart rate, respiration, and generalized myotonia

Plateau Phase

• Vasocongestion reaches maximum levels
• Heart rate, respiration, and blood pressure continue to rise
• Copious perspiration occurs
• Myotonia intensifies
• Males: Bulbourethral (Cowper's) glands secrete pre-ejaculate fluid (may contain sperm), scrotum elevates further, testicles enlarge
• Females: Orgasmic platform forms (outer vaginal wall thickening and swelling, essential for orgasm), tenting is complete, clitoris remains erect

Orgasmic Phase

• Males: Two stage process - contraction of seminal vesicles, vas deferens, prostate followed by urethral and penile contraction (ejaculation)
• Females: Simultaneous contractions of the orgasmic platform and uterus. Multiple orgasms possible with continued stimulation
• Both Sexes: Extremely high heart rate, blood pressure, respiration, and intense myotonia. Oxytocin plays a significant role in female orgasm

Resolution Phase

• Return to normal physiology, muscle relaxation, blood returns from genitals to central circulation
• Males: Have a refractory period (variable length, generally longer with age) before another response is possible
• Females: Potentially no refractory period

Health Benefits of Orgasm

• Potential immune system strengthening
• Pain relief (menstrual cramps, general pain tolerance)
• Lower prostate cancer risk (in men with frequent ejaculation)
• Mood enhancement (estrogen and endorphin release)
• Increased intimacy (oxytocin release)
• Improved sleep (dopamine release)

Retrograde Ejaculation

• Penile urethra has two sphincters: one for urine, one for semen. Normally, one is open while the other closes
• In some cases, the urinary valve opens, causing semen to flow into the bladder instead of through the urethra
• Most commonly related to MS, diabetes, or bladder/prostate surgery
• No harmful effects other than potential infertility (sperm not reaching the egg)

Female Ejaculation

• Anecdotal reports dating back centuries, but research is inconclusive
• Chemical analyses have yielded mixed results: some similar to urine, others similar to prostatic fluid
• Skene's glands (female equivalent of the prostate) may produce a fluid similar to prostatic fluid that is released during orgasm

Gender Differences in Sexual Response

• Women's excitation phase is slower
• Women must have an orgasmic platform to reach orgasm, or they may stay stuck in the plateau phase
• Women can experience multiple orgasms, potentially due to longer lasting vasocongestion
• Men have a refractory period after orgasm, while women theoretically do not

Hormones and Sexual Response

• Testosterone is a key sex hormone, produced by testes, ovaries, and adrenal glands
• It is crucial for sexual desire in both sexes. Free testosterone (unbound) is active
• Women are significantly more sensitive to testosterone but only have 1/10th the amount
• High testosterone levels do not necessarily increase desire or response beyond normal physiological levels

Forebrain Override

• Unlike many animals, human sexual behavior is not solely determined by hormones
• Psycho-social context and culture (forebrain) are the most important factors
• Physiology helps explain how the body functions but is secondary to the forebrain in initiating sexual response

Human Sexual Response

• Four-Phase Model: Excitement, Plateau, Orgasm, Resolution. This model was the first scientific description of the physiology of sexual response and became the basis for defining sexual health and sexual problems.
• Triphasic Model: Desire, Arousal (combined excitement and plateau), Orgasm. This model was introduced by Helen Singer Kaplan in the 1970s as a response to the missing element of desire in the four-phase model.
• Dual Control Model: Introduced by Dr. John Bancroft and Dr. Erick Janssen in the 1990s. This model emphasizes the balance between excitatory and inhibitory processes in sexual response.
  • Neurobiological Inhibition is adaptive, preventing sexual arousal in disadvantageous or dangerous situations.
  • Individual Variability exists in both sexual excitation and inhibition, and can be any combination of low/high excitation or low/high inhibition.
  • Context and Cultural Meaning are crucial stimuli, influencing both excitatory and inhibitory processes.
• Sexual Excitation System: Acts as an "accelerator," responding to sex-related stimuli and triggering genital arousal.
• Sexual Inhibition System: Acts as "brakes," providing neurological "off" signals.
  • Potential Threat Inhibition: Activated by environmental cues like sights, sounds, smells, touch, taste, or thoughts.
  • Chronic Inhibition: Persistent low-level inhibition linked to fear of performance failure.
• Sexual Arousal requires both activation of the accelerator and deactivation of the brakes.
• Sexual Dysfunction can arise from insufficient accelerator stimulation or excessive brake stimulation.
• High Brake Sensitivity is a strong predictor of various sexual problems, particularly low desire/low libido.
• Context and Brain State: The circumstances of the moment and the brain's current state significantly influence sexual function. Key questions to consider for sexual difficulties:
  • How sensitive is the accelerator?
  • What activates the accelerator?
  • How sensitive are the brakes?
  • What activates the brakes?
• Stress: During stressful times, the brain interprets everything as a threat, usually leading to reduced sexual interest and pleasure.
• Arousal Non-Concordance: This describes a disconnect between the mind and body's response to desire and arousal.
  • It can occur when the body responds to non-sexual stimuli with arousal or fails to respond to sexual stimuli.
  • Suggestions for those experiencing non-concordance include reassurance of their health and functionality, encouragement to communicate with partners, and lubricant use.
• Desire and Pleasure in Context:
  • Spontaneous Sexual Desire arises in anticipation of pleasure.
  • Reactive Sexual Desire emerges in response to pleasurable experiences.
  • Both are normal and healthy responses.
  • Research suggests that half of women may be categorized to either spontaneous or responsive desire.
  • Desire is often context-dependent, emerging when the context is favorable, and stimulation is pleasurable.

The Range of Human Sexuality

• The World Health Organization defines sexual health as physical, emotional, mental, and social well-being related to sexuality.

Sexual Terms and Definitions

• Biological Sex: refers to genetic and anatomical characteristics.
• Intersex: previously known as “hermaphrodite,” individuals with ambiguous genitalia.
• Gender: a psychosocial concept of maleness and femaleness.
• Gender Identity: a person's subjective sense of being male, female, or nonbinary.
• Gender Expression: how an individual chooses to present themselves in public (behavior, clothing, etc.).
• Sexual Orientation: describes an individual's sexual attraction to men, women, or both.
• Transgender/Cisgender: refers to the relationship between a person's gender identity and their biological sex.
• Queer: a term used to describe anyone with fluid sexuality or gender identity/expression, now embraced by the LGBTQIA community.
• LGBTQIA: Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, Asexual.

Kinsey's 7-Point Continuum

• A model that depicts a spectrum of sexuality, ranging from exclusively heterosexual to exclusively homosexual behavior.
• Outdated, as it was developed in 1948.

DSM-5: Diagnostic and Statistical Manual of Mental Disorders

• Sets criteria for mental disorders, including sexual dysfunctions.
• Considers behavior, onset, duration, context, effects, and consequences.
• Evolving changes in diagnosing sexual dysfunction include:
  • Changes in terminology.
  • More specific criteria for diagnosis.
  • Duration of at least 6 months to differentiate from transient dysfunction.
  • Causes distress.
  • Some prior diagnoses have been deleted or revised into a single category.

Sexual Dysfunctions

• Disorders affecting the sexual response cycle (excitement, plateau, orgasm, resolution).
• Affects up to 30% of men and 50% of women at some point.
• Lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems.
• Often interrelated, with patients experiencing multiple dysfunctions.
• Must meet specific criteria, have a duration of at least 6 months, cause distress, and not be due to a medical or non-sexual mental disorder for diagnosis.

Contributors to Sexual Dysfunction

• Biological Causes:
  • Hormonal interactions/deficiencies.
  • Chronic illness.
  • Medications/Drugs.
  • Vascular problems.
  • Genetic predisposition.
• Psychological Causes:
  • Anxiety, depression, anger, or other psychological disorders.
  • Cultural beliefs, attitudes, and memories.
• Sociocultural Causes:
  • Situational pressures (divorce, death, job stress, infertility, relationship difficulties).
  • Cultural standards.
  • Trauma of sexual molestation or assault.

Basic Types of Sexual Dysfunction in DSM-5-TR

• Hypoactive Sexual Desire Disorders:
  • Lack of interest in sex and little sexual activity.
  • Absent/reduced initiation of sexual activity.
  • Absent/reduced response to erotic cues.
• Male Erectile Disorders: Difficulty getting or maintaining an erection.
• Male Ejaculatory Disorders:
  • Premature Ejaculation: Reaching orgasm and ejaculating with little stimulation.
  • Delayed Ejaculation: Difficulty reaching orgasm or delayed orgasm after normal sexual excitement.
• Female Sexual Interest/Arousal Disorder: Difficulty with sufficient lubrication for sexual intercourse.
• Female Orgasmic Disorder: Difficulty reaching orgasm.
• Genito-Pelvic Pain/Penetration Disorder:
  • Pain during intercourse.
  • Tightening or tensing of pelvic floor muscles making sex difficult or impossible.
  • May include Vaginismus and Vulvar Vestibulitis.
• Substance/Medication-Induced Sexual Dysfunction: Be sure to obtain a full list of medications.

Disorders and Sexual/Physical Abuse

• Not a sexual dysfunction diagnosis but may be a contributing factor.
• Maintain a high index of suspicion, especially when symptoms don't fit the expected pattern.
• May include:
  • Coerced sex.
  • Depression.
  • Self-mutilation.
  • Anxiety.
  • Post-traumatic stress disorder (PTSD).
  • Fear of intimacy.
  • Sexual acting out.
  • Sexual dysfunction.
• Legal reporting obligations may apply depending on the state.

Sexual Desire

• Determined by a combination of biological, psychological, and sociocultural factors.
• Most cases of low sexual desire or sexual aversion are caused by sociocultural and psychological factors.
• Biological conditions can significantly lower the sex drive.
• Testosterone is helpful for sexual desire only if levels are sub-clinical.

Hypoactive Sexual Desire Disorder

• Characterized by lack of interest in sex and little sexual activity.
• Present at least 6 months.
• Causes significant distress.
• Not better explained by another non-sexual factor (stressors, major depression, drugs, etc.).

Premature Ejaculation

• Characterized by reaching orgasm and ejaculation quickly with minimal stimulation.
• Affects around 30% of men at some point.
• Often associated with younger men early in sexual maturity.
• May be related to anxiety, hurried masturbation experiences, or poor recognition of arousal.
• Often associated with erectile disorder.
• Criteria for diagnosis:
  • Present for 6 months.
  • Occurs > 75% of occasions.
  • Causes significant distress.
  • Not better explained by another diagnosis.

Delayed Ejaculation

• Characterized by repeated inability to reach orgasm or delayed orgasm after normal sexual excitement.
• Prevalence is uncertain, but less than 1% of the population experiences symptoms for over 6 months.
• May cause psychological distress and contribute to delayed conception.
• Criteria for diagnosis:
  • Duration of 6 months.
  • Causes significant distress.
  • Not better explained by another diagnosis.

Female Orgasmic Disorder

• Characterized by delayed, absent, or reduced intensity of orgasmic sensations.
• Prevalence: 10-40% of population.
• Ensure sufficient physiological stimulation is occurring.
• Do not diagnose when significant relationship or context factors are present.
• Criteria for diagnosis:
  • Duration of 6 months.
  • Causes significant distress.
  • Not better explained by another diagnosis.

Genito-Pelvic Pain/Penetration Disorder

• Represents a combination of Vaginismus and Dyspareunia.
• Vaginismus: involuntary contractions of the muscles of the outer third of the vagina.
• Dyspareunia: severe pain in the genitalia during sexual activity.
• Significant overlap with prior physical/sexual abuse.
• Criteria for diagnosis:
  • Duration of 6 months.
  • Causes significant distress.
  • Not better explained by another diagnosis.
  • Evaluate for underlying medical conditions (lichen sclerosis, PID, etc.).
  • Frequently occurs with other sexual dysfunctions, relationship distress, or sexual assault.

Vulvar Vestibulitis Syndrome (VVS)

• Likely caused by a "neuro-inflammatory" condition and can cause vaginismus.
• Burning pain at the opening (vestibule) of the vagina.
• Pain present during daily activities and sex in severe cases.
• Treatment options include estrogen cream, lidocaine application, and vestibuloplasty.