Sex And Psychiatry

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Sex And Psychiatry

• Dr Riccardo N Caniato

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Qualifications

• MBBS
• FRANZCP
• Sexual Health Clinic
• Forensic Psychiatry
• Private Practice

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Sexual problems

• Importance of Sexual functioning
• Sexual dysfunction or issues are common and
  distressing
• Sexual dysfunction/ disorders are an unclear area
  of medicine
• Complex ethical issues
• Common primary diagnosis
• Common co-morbidities to mental illness
• Secondary to psychiatric medications

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Clinical Scope

• 1) Sexual dysfunction- arousal, interest and
  performance
• 2) Paraphilias/ arousal disorders
• (Paedophilia / sexual offending)
• 3)Transgender disorders/gender identity disorders

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Classification-DSM IV

• Sexual and gender identity disorders
• 1) Sexual dysfunction
• 2) Paraphilias
• 3) Gender identity disorders

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Classification- ICD 10

• F 52- sexual dysfunction not caused by organic
  disorder or disease
• F 64 gender identity disorders
• F 65 disorders of sexual preference
• F 66 psychological and behavioural disorders
  associated with sexual development and
  orientation

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Other classification systems

• CCMD-3
• Culture bound syndrome
• Koro

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Key issues / differences

• Sexual preference/orientation (adults) no longer
  considered a disorder (removed from DSM and ICD)
• Ego dystonic sexual orientation coded for in ICD
  but not DSM IV
• Paedophilia is universally considered abnormal
• No general category for perpetrators of adult
  sexual assault (but there is for victims)

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Aetiology of sexual function

• Complex
• Multiple factors
• Biological
• psychological
• social
• Poorly understood

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1) Sexual dysfunctions - (interest, arousal, and
performance)

• A) sexual desire disorders
• Hypoactive sexual desire disorder
• B) sexual arousal disorder
• Sexual aversion disorder
• Male erectile disorder
• C) orgasmic disorders
• Premature ejaculation
• D) sexual pain disorders
• Dyspareunia
• Sexual dysfunction nos
• A, B, C or D Due to GMC

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Epidemiology

• High-
• Very hard to get valid statistics
• Usually secondary in clinical practice- ( mental
  health issues, substance use, medications or GMC)
• Males
• Erectile
• Interest
• Orgasmic

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AssessmentTo ask or not too ask

• Not part of a usual medical interview
• Difficulty of ascertaining normality
• Role of physician- line between a medical problem
  and a lifestyle issue
• Marked individual variations
• Usually a secondary person / patient
• Subjective change and dissatisfaction is most
  common marker- can be flawed
• Change in functioning- normal change with age

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Presentation

• Sexual problems are rarely the PC
• Asking- vs Ticket of entry
• Assess comorbidity- depression
• Medical history
• Psychiatric history
• Medications
• AD, antihypertensives,
• Drug and alcohol history

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Sexual History How much do you really want to
know

• Guidelines to taking a sexual history (medical)
• Psychological Guidelines for assessing sexual
  functioning
• More detailed- frequency, duration, quality,
  dreams, fantasies
• how is your sexual functioning
• Relationship quality
• Structured interviews or standardised self
  reported assessments

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Psychometric assessments

• Standardised
• Less time consuming
• comparative
• SFQ
• AMS
• Marital relationship

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Investigations

• Hormone assays- testosterone, free testosterone,
  FSH
• Prolactin
• Markers of vascular pathology- smoking,
  cholesterol, blood pressure
• Drug/ alcohol use- LFTs CDT cannabis

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Diagnostic formulation

• Diagnosis
• Primary or secondary
• co-morbidities
• Formulation- main biological, psychological and
  social factors

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a) Major Depression

• Probably Main comorbidity to sexual dysfunction
• Depression nearly always affects sexual function
• Nearly all antidepressants affection sexual
  functioning
• Further comorbidities
• Medical
• Substance use

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Case Report 1

• MR PG 56 year old male with depression,
• You have Treated with him with lexapro 20 mg, but
  he is still depressed
• Other medications are, simvastatin 10 mg,
  verapamil, diaformin
• Hx of hypertension, obesity, snoring, smoking,
  drinks 10 drinks/ week
• Investigations- borderline low testosterone,
  poorly controlled diabetes, bp 150/90
• At the end of the session he mentions than he
  hasnt had sex for a while

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Causes of his sexual dysfucntion

• Multiple
• Depression
• Medical problems
• Vascular risks
• Medications
• Substance use

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Treatment guidelines ??Whats most important

• A) Treat major depression
• -assumes if depression improves, sexual function
  should improve
• B) Target his medical problems
• -main focus as medical practitioners
• C) Target substance use
• D) Treat sexual functioning
• -assumes if sexual functioning improves,
  depression improves
• E) simultaneous assessment and treatment

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Pharmacotherapy of sexual dysfunction in
depression

• A) Antidepressant treatments with fewer sexual
  side effects
• B) Medications that improve sexual function
• C) Minimising general medication with sexual side
  effects
• D) target substance use

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Sexual side effects of AD

• SSRIs- very high rate of sexual side effects 30
  -70
• Impaired orgasm
• Reduced interest

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Neurotransmitters of sexual function (Stahl)

• Interest
• Dopaminergic (mesolimbic reward system)
• Testoserone
• Estrogen
• Arousal
• NO (nitrous oxide)
• acetylcholine
• Orgasm
• serotonergic -ve
• noradrenaline ve
• Others- mutliple-

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a) Change to antidepressants with lesser sexual
effects

• Buproprion- dopaminergic
• Trazodone- atypical priapism
• Nefazadone- 5 HT2a agonism
• Reboxetine (noradrenergic)
• Mirtazepine- 5HT2A (agonism)
• Moclobemide-RIMA
• SNRI-s Noradrenergic function ? Duloxetine

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b) Reduced antidepressant dose

• Reduce at earliest time frame ( dose dependant)
• Adjuvant with few side effects
• Lithium, thyroxine, seroquel
• Buspirone- (antidepressant/ adjuvant)
• Testosterone

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c) Medications for improved sexual functioning ??

• a) Erectile medications
• b) Testosterone

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Other putativesexually enhancing compounds

• Cyproheptatine (periactin) a first-generation
  antihistamine with additional anticholinergic,
  antiserotonergic, and local anesthetic
  properties. Improve SSRI-induced sexual
  dysfunction1516
• Yohimbine Yohimbine is an alkaloid with
  stimulant and aphrodisiac effects found naturally
  in Pausinystalia yohimbe (Yohimbe). Yohimbine
  blocks the pre- and post-synaptic alpha-2
  adrenoceptors.
• Gingko biloba
• apomorphine, (dopaminergic)
• methylphenidate,- stimulant (sympathomimetic)
• Parkinsonian
• Opiods acute phase

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Sexual functioning and AnxietyDisorders


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Mental State Examination
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The Anxious Male
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Anxiety Disorders

• GAD
• Panic disorder (with or without agoraphobia)
• Social Phobia
• PTSD
• OCD

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Anxiety disorders

• State of flux
• Complex overlap with depression
• Under-diagnosed in males
• Difficult to diagnose in males (with the
  exception of PTSD)
• Far bigger stigma that depression or PTSD

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Relationship of anxiety and sexual dysfunction

• A) Anxiety and premature ejaculation
• (adrenergic system)
• B) Anxiety and reduced desire
• (in some people)
• C) Anxiety and sexual avoidance
• (sexual aversion disorder)
• D) Sexual phobias/ panic
• E) Anxiety and avoidance of potential partners

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Case 2

• 25 year old veteran from IRAQ conflict being
  treated for PTSD and GAD
• Anxiety in social situations, public places,
  driving, social phobia, agoraphobia
• Increasing alcohol consumption
• No / reduced sexual interest
• ? Anxiety
• Sexual anticipatory anxiety, avoidance, anxiety,
• ? Sexual aversion disorder (DSM)

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Treatment- antidepressants

• A) Standard antidepressant treatment
• For anxiety
• For premature ejaculation
• B) Anxiolytic antidepressants
• -paroxetine
• -TCA-especially clomipramine
• (Anticholinergic antidepressants- TCAs, aropax
  (ACH)

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Anxiolytics

• Alcohol (self medication)
• Benzodiazepines (GABA ergic)
• B blockers- propranolol
• Calming antipsychotics (vs prolactin)
• Antipsychotics
• -Dopaminergic,
• -Seroquel
• Buspirone (azapirone anxiolytic)
• GAD, depression (off label)
• 5-HT1a partial agonist, dopamine, adrenergic

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Case 3

• MR AG 22 old male,
• vomiting after orgasm (post coital / orgasmic
  symptoms)
• Other low grade anxiety symptoms
• Diagnosis

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3) Psychotic disorders

• Complex effect on sexual function- schizophrenia
• Bipolar affective disorders- cyclical changes
• Antipsychotics- anti-dopaminergic
• - prolactinergic
  (Dopaminergic)
• - other

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Antipsychotics

• Dopaminergic effect-reduces drive and sexual
  function
• Prolactin raising effect- primary effect on
  sexual functioning
• Indirect reduction of testosterone

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Mood stabilisers

• Very limited data on sexual dysfunction
• On face value, reason to believe they have lesser
  incidence of SSE

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ParaphiliasNo women allowed

• Almost exclusively the domain of men
• Exibitionism
• Fetishism
• Frotterism
• Paedophilia
• Sexual masochism
• Sexual sadism
• Transvestic fetishism
• Voyerism
• Paraphilia NOS

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Paedophilia- Role of general physician

• A) to detect
• B) to recognise
• C) to predict
• D) to alert
• E) to treat
• F) to monitor

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Pharmacology

• Reduce sexual drive
• Reduce arousal
• Reduce obsessive/ intrusive thoughts

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Reducing Sexual Functioning

• ? Sexual offenders
• ? Intellectual disabilities- controversial
• ? dementia

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Medications

• Androcur
• GnRH antagonists
• Dopaminergic antipsychotics
• Prolactinergic
• SSRIs- sexual and anti obsessive effects

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Sex offenders

• Complex
• Recognising paedophilia
• Roles in informing
• Role to explore
• Prediction of sexual offending
• Role in complex custody issues
• Taking a sexual offence history

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Predicting sexual (re)offending

• Various tools available
• HCR-20
• SVR
• STATIC-99
• H-PCL
• History of previous offence
• History of previous allegations

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Case 5

• Ms B and her two male children aged 5 and 6
  present.
• Her children are the identified patients
• They are being assessed for anxiety disorders
• She has had an acrimonious separation
• She mentions she is worried her children are
  being sexually abused on fortnightly custody
  visits

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Gender Identity disorders

• Identity disorders, may overlap with arousal
  disorders
• Sexual Gender preference does not classify as a
  disorder

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DSM IV

• A) Gender identity disorder
• B) Transvestitism
• C) Fetishism

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Aetiology

• Biological
• Psychological
• Social
• Cultural

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Psychodynamic formation of identity- controversial

• Freud- Oedipal and Electra complex
• Ie you should idealise/model same sex parent
  and feel nurtured/attracted to opposite sex
  parent
• Kohut- formation of identity young age (3-8)
• Gender identity established by age of 3
• Gender identity can sometimes be linked to more
  general formation of a sense of self

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a) Male -gt Female

• Most common (4 times)
• Early and late onsets
• Common in the media
• Complex culture bound factors

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Early onset

• Identified and lived as female from a young age
• Is evident in childhood or adolescence
• Feminine appearance and behaviours
• Usually have some level of family support

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Late Onset

• Have had clear male identity
• Often married with children
• Overtly masculine behaviours and occupations
• High levels of comorbidity- depression and anxiety

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Diagnosis- Gender identity disorder

• A) Persistent and strong cross gender
  identification
• B) persistent discomfort with his or her sex or
  sense of inappropriateness in the gender role of
  that sex
• C) the disturbance is not concurrent with an
  intersex condition
• D) the disturbance causes clinically significant
  distress

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Assessment

• Rule out medical pathology
• Rule out primary causative psychiatric disorder-
  psychosis
• Rule out other psychological causes
• Diagnose and treat comorbidities
• Document informed consent
• Inform and educate

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Treatment Principles

• We do not do specific psychotherapies to change
  sexual identity or sexual oriention
• Establish informed consent
• Provide education
• Link in with mental health/ psychological
  services
• Hormone treatment- anti-androgens, estrogens
• Legal issues
• Referral for surgical interventions

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Prescribing Hormones

• ? Prescribe and moniter hormones
• ? Refer to specialists
• Estrogens- standard dosages
• Antiandrogens-
• Moniter bloods
• Watch for excessive use

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Surgical intervention

• Main bottle neck
• Breast augmentation
• Cricoid surgery
• Facial surgery
• Orchidectomy
• Phallectomy and vaginal construction

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Case Review

• 44 year old male to female
• Underwent gender reassignment surgery 2009
• Currently living as female
• Is regretting surgery
• Was probably depressed at the time
• Now presents wanting a clearance to go to a
  plastic surgeon to have breast implants removed
  and to transition back to male
• Also wishes a letter to access his superannuation
  for the surgery

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b) Female to male

• Significant differences to M-gtF
• Surgical differences are greatest issue
• Hormones- male hormone

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Treatment issues

• Male hormone
• Issues of fertility and consent
• Assessment for mammoplasty and hysterectomy
• Phalloplasty is not possible

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c) Alternate Genders

• Social theorists see gender as dimensional rather
  than categorical
• Some advocates conceptualised more than two
  genders
• -transgender