• Relative hairlessness of our body
• Clitoris with sole function for inducing female sexual arousal/pleasure
• Orgasms
• Penis, whether flaccid or erect, act as sexual stimulator of female genitalia
• Concealed ovulation
• Well-defined sexual displays in female that are not linked to season or fertility
• Ability of female to undertake sexual arousal and coitus independent of season, hormonal status, or ovulation
• Development of large mammary glands during puberty

• Language, art, music
• Facial adornment with make-up
• Clothing
• Perfumes and scents

• 12000 male in 1948 and 8000 female in 1953
• Females tend to under-report their premarital sexual experiences while males tend to over-report their lifetime partners

• Men thought about sex often, more than 50% having erotic thoughts several times a day, while females thought about sex from a few times a week to a few times a month
• Frequency of partnered sex had little to do with race, religion or education
• Only 3 factors mattered: age, married or cohabiting, duration of relationship
• Reported sexual practices depend on race and social class
• Most practices other than vaginal coitus were not very attractive to the vast majority
• 85% of male and 80% of female rated vaginal coitus "very appealing"
• Oral sex: both men and women liked receiving more than giving
• Higher reported rates among better educated white people
• Anal sex: 73% of male and 87% of female thought it not at all appealing
• Sexual desire ® (1) Spontaneous sexual desire: more in men (2) In response to being touched/ kissed - etc.

• Masters and Johnson 1970
• 4-phase linear, sequential, and incremental model
• Excitation (E): stimuli from somatogenic or psychogenic sources raise sexual tensions
• Plateau (P): sexual tensions intensified
• Orgasmic (O): involuntary pleasurable climax
• Resolution (R): dissipation of sexual tensions
• Weakness ® Derived from study of a highly selected group; Lack of inter-observer agreement

• Helen Kaplan 1974
• Proposed that before E phase there should be a "desire phase" (D)
• Courtship behaviour ® Sometimes precedes the D phase, sometimes during the D phase, and sometimes in the E phase
• Most men are first visually attracted to a possible female sexual partner
• They look for youthfulness and physical attractiveness
• Women need to obtain high-quality mates with abundant resources and look for emotional and financial status and security
• Once the chosen female or male accepts the initiation of courtship behaviour, the subsequent stages form a stereotyped sequence
• Look ® approach ® talk ® touch ® synchronise ® kiss ® sex play ® coitus

• Androgen
• Secreted by testes mainly as testosterone
• 95% bound to plasma protein
• Only the unbound fraction is an active virilising hormone
• Development of masculine musculature, bone growth, genitals, pubic and axillary hair growth
• Removal of testosterone by castration usually leads to a decrease in sexual activity and drive in majority of subjects within 12 months
• 2 systems in the brain that control erections

1. Androgen-dependent system: impaired nocturnal erection
2. Androgen-independent system: involved in erectile response to visual erotic stimuli

• Oestrogen, progesterone, and androgen
• Involved in differentiating and maintaining genital and breast tissues and in influencing normal sexual function
• Neither oestrogen or progesterone have been found convincingly to play a direct role in influencing the sexual activity
• Androgen: proposed to be the hormone affecting female libido

• 3442 American individuals aged between 18 and 59 years
• Female ® 33% reported lack of interest in sex; 17% had difficulty with arousal; 24% were unable to reach orgasm; 21% said sex was not pleasurable; 14% complained of pain with coitus
• Male ® 16% reported lack of sexual interest; 10% identified erectile difficulties; 29% complained of ejaculating too quickly; 17% acknowledged anxiety about performance

• Share the basic nomenclature and model for sexual dysfunction
• Different in specificity of diagnosis
• For each DSM-IV sexual disorder, the clinician is required to make 3 judgements:

1. Whether the dysfunction is lifelong or acquired
2. Whether it is of a generalised or specific type
3. Whether it is due to psychological or combined biological and psychological factors

• Sexual desire: conceptualised as the product of the mind's capacity to integrate 3 separate elements: drive, wish and motive
• Drive: neurophysiological generator inducing internal phenomenon labelled as "horniness or randiness"
• Wish: cognitive component through which intellectual motives are translated into behaviour
• Motive: combination of affective, transferential and attachment response that impel one to engage in or avoid sexual experiences

• Male: circulating level of free testosterone
• Female: difficult to measure

• Strong negative emotions result in diminished sexual desire
• Men and women with generalised hypoactive sexual desire had higher lifetime prevalence of depressive disorder which had preceded the development of sexual disorder
• Associated with lower level of marital satisfaction and lower feelings of romantic love toward the partner
• History of childhood sexual abuse or gender identity conflict has been associated with generalised hypoactive sexual desire in some women

• No objective criteria of normal sexual desire
• Require subjective judgement about whether a deficiency, lack of interest, or absence of sexual desire exists
• Not diagnosed simply because one partner complains that the other is lacking desire, and not diagnosed when it fails to cause marker distress

• Thorough medical and pharmacological history
• Patient's quality and quantity of sexual imagery in daytime fantasies and night dreams
• Desire to engage in sexual behaviour both alone and with a partner
• Frequency of sexual activity, alone or with a partner
• Individual's life context: age, health and partner status
• Psychological and relational factors
• Quality of relationship
• Feelings about the partner
• Impact of extramarital liaisons
• Sexual orientation incompatibility between self and partner
• History of childhood or adult sexual trauma
• Negative parental transferences and current or prior history of affective disorder
• Life circumstances that result in negative emotions

• Psychotherapeutic interventions: behavioural, cognitive, psychodynamic, and marital techniques
• No specific treatment regimes have been agreed
• Testosterone may be helpful to certain groups of women

• Extreme forms of desire disorders differentiated by emotion of intense aversion to or disgust with sexual activity, rather than the more typical lack of interest in sexual behaviour
• May be due to traumatogenic aetiology eg. early sexual abuse, painful experiences with coitus, or the perception of being assaulted by the partner

• Pharmacological and psychological interventions tend to mirror the interventions for hypoactive sexual desire

• Lifelong or primary ED: developmental failure to become comfortable with adult forms of sexuality
• Acquired or secondary ED: result from interpersonal struggles, for instance marital discord, or intrapsychic phenomena
• Some form of anxiety, usually performance anxiety, is responsible for the development and maintenance of lifelong and acquired ED
• 6 phases of management

1. Establishing the diagnosis ® conjoint effort of mental health clinician and urologist; onset and course; quality of erection under various circumstances; other relevant parameters of sexual life

1. quality of the couple's non-sexual relationship
2. discussing the initial findings, discussing referral, beginning the education process
3. modifying reversible causes of ED
4. implementing first-line treatment ® psychotherapy; oral erectogenic agents; vacuum constriction devices
5. implementing second-line treatment ® self-infection therapy; transurethral therapy
6. implementing third-line treatment ® implantation of penile prothesis

• typically diagnosed in women with complaints of diminished lubrication or painful intercourse
• Assessment ® Begins with separating out problems of desire and orgasm; Relationship satisfaction; Current life stressors; Subjective arousal to a wide range of conventional stimuli; An integrated medical-psychological approach
• Treatment ® Few empirically validated or anecdotal reports of psychological treatment interventions; Techniques to facilitate increased arousal; Topical lubricants

• Diagnosis based on the clinician's judgement that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience and the adequacy of sexual stimulation she receives
• 10-15% of women have anorgasmia
• Only one-third of women are able to regularly achieve orgasm through intercourse alone
• Assessment ® Whether the patient has ever experienced an orgasm before; How reliable and under what circumstances it occurred; The woman's ability to relax, sustained and heighten her arousal; Relationship with partner; Medical problem e.g. spinal cord injury
• Treatment ® Masturbatory training programmes; Sensate focus

• Rapid ejaculation ® Ejaculation occurring without voluntary control and with minimal sexual stimulation
• Aetiology ® Lowered ejaculatory threshold stems from anxiety, general hostility towards women, interpersonal conflicts with a particular partner, or conditioning patterned on furtive masturbation practices, early hurried sexual experiences with prostitutes, etc.
• Performance anxiety was thought to maintain the rapid ejaculatory pattern
• Assessment ® How long it takes the man to reach orgasm under different circumstances; Expectations; Sexual experiences; Life events temporally related to the onset of the problem;
• Quality of non-sexual relationship with partner; Organic factors
• Treatment ® Behavioural treatment; Sensate focus exercises; Psychopharmacological treatments (MAOI, Tricyclic and serotonergic antidepressants, Antipsychotics, Alpha-adrenoceptor blocking agents,
• Delayed ejaculation ® Much rarer
• Aetiology ® Spinal cord injury and other neurological conditions; Drug induced (anti-HT, SSRI, TCA, phenothiazines, benzodiazepines)
• Assessment ® Whether he is able to ejaculate in various conditions; Course of problem; His ability to relax, sustain and heighten arousal; Societal/religious attitudes; Non-sexual relationship
• Treatment ® Combination of sensate focus, vigorous non-coital penile stimulation, and modification of intercourse technique; Vibrator stimulation

2 dysfunctions: non-organic dyspareunia and vaginismus

• Genital pain in either male or female
• Recurrent and persistent genital pain before, during and after sexual activity
• Currently the only female sexual dysfunction in which organic factors played major role
• Anatomical: congenital or developmental impairments
• Pathological: acute and chronic infection of the genital tract
• Iatrogenic: after surgical procedures
• Ranges from mild to unbearable pain
• Rare in men

• Not necessarily limited to sexual situations
• Unable to insert tampons or permit insertion of speculum during gynae exam
• Hypothesised to be the body's expression of psychological fear of penetration
• A spectrum of etiological factors e.g. specific traumas, interpersonal and intrapsychic conflict, penetration anxiety, multiple organic pathologies, etc
• Assessment ® Careful exam for subtle anatomical, pathological or iatrogenic factors; Locus of pain, onset, average duration of pain episode; Influence of symptoms with sexual life; Conditions under which any penetration of the vagina can occur; Couple's sexual style; Childhood and adult sexual history; Non-sexual relationship
• Treatment ® Medical interventions such as intravaginal oestrogen cream or anaesthetic ointment; Surgical repair of vulvar region; Sex therapy

• Orgasmic platform: wall thickened, penis can still be inserted
• Vaginismus: involuntary contraction of external vaginal muscles; fear of penetration

1. Excitement ® Clitoris enlarges; Labia swell; Vaginal lubrication (transudate, not exudate)
2. Orgasm ® Rhythmic contracts of orgasmic platform; Uterus contractions; Rectal sphincter contracts
3. Plateau ® Uterus elevates; Colour change in labia; Vagina expands (tenting); Orgasmic platform reduces
4. Resolution ® Uterus lowers; Orgasmic platform disappears; Vagina returns to normal; Seminal pool

• Y sperm weaker: uterus contraction helps Y sperm go up into uterus and fertilise egg
• Theory: if woman has orgasm, higher chance baby will be boy
• Remaining supine after sex, increased chance of fertilisation
• Getting up after sex - not less likely to fertilisation

1. Multiple orgasm
2. Arousal to plateau level without achieving orgasm: slower resolution
3. Brief drops in excitement phase followed by rapid resolution

• Men can also have multiple orgasm (but dry orgasm). Ejaculation usually accompanies orgasm, but not always

• Foreplay: 90 bpm
• Foreplay: 115 bpm
• Intromission: penetration
• Ejaculation + orgasm: 155 bpm
• During foreplay the male pulse rate slowly increases, then with intromission it reaches a high plateau level and finally peaks at 150 ml with ejaculation

• Spur of the moment
• Curiosity

• Men peak at 17 yo (7x one night)
• Age 70 yo: 7 days recovery period

• Psych factors are among the most common factors for ED
• Lesions in the anterior temporal lobe (vascular, traumatic)
• Complete suprasacral SC lesion, which allowed erection of either reflexogenic or psychogenic origin
• Complete intrasacral SC lesion, which abolishes erection
• Autonomic neuropathy leas to impotence (such as DM)
• Radical pelvic surgery can cause damage to the local nerve plexus (eg. Abdominoperineal resection of the rectum)
• Drugs that inhibit action of ACh
• Major vascular occlusion the ab or pelvis, which impedes blood supply to the penile tissue

Etc.

• Testosterone: most important for libido
• Some older women, use testosterone to increase sexual desire
• Also use HRT to keep sexual organs functional (eg. Oestrogen cream to retain elasticity of vagina)

• Usually settles spontaneously, but rarely may be severe enough to warrant breast reduction
• Prolactin: esp. if galactorrhoea (which decreases libido)

• High oestrogen
• Low oestrogen
• Have different effects

• During pregnancy, prolactin remains high (which decreases libido)
• Therefore, many puerperium woman not interested in sex
• Also, tired, care of baby, change of roles
• Father jealous of baby

• OA
• Disfigurement
• Stoma
• Mastectomy
• Peyronie's deformity: presence of dorsal plaque in penis (idiopathic; affects function)
• Hysterectomy
• Any physical disease
• Smoking
• Alcohol: men may have avoidance personality, social phobia -> alcohol is a sedative, removes inhibition (alcohol increases the desire, but decreases the performance)
• Ecstasy
• Relationship factors

1. Passion: sex
2. Intimacy: talk
3. Commitment: marriage (for example)

• Only sex: sex
• Only talking: friends
• Only commitment: arranged marriage
• Only passion + intimacy: romantic love
• Only talking + commitment: old people married for a long time
• Only sex + commitment: 'Hollywood' relationship

• Place seats at side of desk in a more friendly arrangement for an interview and makes it easier to observe a couple's body language to each other, which gives clues to their relationship
• If couples come together for counselling, good prognosis
• If no cure within 10 sessions, poor prognosis

• Appropriate to use colloquialisms?
• Cultural differences (eg. Muslims cannot participate in oral sex - therefore don't suggest)

• Break 1: pain, inappropriate stimulation [break of body sensations
• Break 2: Anxiety, fear of failure, anger, grief [break before emotion: trust, love, intimacy]
• Break 3: Distraction, spectatoring [break before fantasy + knowledge)

• Pain
• Fear of pain
• Partial avoidance of sexual activity
• Sexual arousal disorder
• Orgasmic disorder
• Loss of sexual desire (+ve feedback on fear of pain)
• Loss of sexual desire
• Total avoidance of sexual activity
• Relationship difficulties

• Masters & Johnson
• No intercourse for period
• For both female and male sexual dysfunction
• 3 steps

1. Sensory focus: touching of non-genital areas (both parties) - the one receiving has to concentrate on acceptance of feeling, feedback to 'toucher'
2. Sensory focus: genital areas including breast, feedback, etc
3. 3 substages

1. Containment: putting penis inside vagina (female on top/ superior)
2. Movt
3. Orgasm

• Carrier oils, aromatherapy
• Beware: can cause condom to break

• Can find by stopping flow of urination
• Repeat 9 times, after 10th time, empty UB completely
• When can contract anywhere (eg. Bus, sitting) - contract 300x/ day
• Men: control ejection, ejaculation
• Women: pelvic floor
• Originally developed for woman post-childbirth (to prevent incontinence)

1. General lifestyle change
2. Sensory focus
3. Keigel exercise

• If marital problems, they may interfere with sexual function - therefore may need marriage counselling and sexual counselling at same time
• Eg. Incompatibility of sexual desire ® Men anxious of being rejected; Woman anxious of man wanting sex \ Solution = timetable (decided by couple)

• Commonest presentation of women at sex clinics
• Either accompanied by pain or painless
• Spread to other areas: cannot insert finger, speculum into vagina
• Tx: 90% cure rate by progressive dilatation (Amielle trainers) - behavioural therapy (change behaviour, and consequently change emotion and cognition associated with that behaviour)
• Dilators hard to buy - therefore use finger (Pt's, then partner's)
• Cause: fear of vaginal penetration

• Dyspareunia: deal with primary cause; try different positions to lessen pain

Men only

ICD-10: limit of 15 seconds/ 10 strokes

1. SPRAYS ® Eg. "Studd 100": sprays incorporating lidocaine are used to delay ejaculation (but irritating to vagina); Ask Pt: how long he wants to last - then try to match expectation of Pt with performance
2. MASTUBATORY TRAINING ® Mastubatory training: modifying the stimulating in masturbatory exercises, a man with premature ejaculation can learn to slow his response - eg. "Stop-start" method ® Masturbation; Coitus (female superior) [Note: if ejaculate into posterior urethral bulb, no stopping of ejaculation (PC muscle is above the bulb; therefore can use this muscle) ® male multiple orgasm (?)] [Maturbatory exercise can also be used in women who are not aroused]
3. PAUSE & SQUEEZE ® 'Pause + squeeze" technique: squeeze penis until pain, causes loss of 1/2 of erection - can improve ejaculatory control
4. SSRI ® Selective Serotonin Reuptake Inhibitor; Delays orgasm by increasing serotonin levels; Disadvantage: serotonin decreases libido
5. TCA ® Chlormipramine: serotinergic

• After spinal injury
• Eg. Ferticare personal vibrator - effective in 80% of Pt's (help men with SC injuries to ejaculate)
• Fear of having children (unconsciously stops ejaculation)
• Semen phobia (also phobia of vaginal secretions)

• Situation sexual dysfunction: erectile dysfunction with wife but girlfriend
• Generalised sexual dysfunction: erectile dysfunction with everyone
• Acquired: normal previously, acquired dysfunction
• Ask man: have morning erection? If yes, retain biological functioning (therefore psychological or relationship)

• Corpus cavernosum more important for erection
• Glans is continuation of spongiosum
• Sensitive area: glans up to coronal sulcus

• FLACCID ® Smooth muscle in tonic state, maintaining flaccidity; Lacunar space smaller, blood exits
• ERECTION ® Trabecular muscle is relaxed; Lacunar space large; Veins compressed; Outlfow decreased; Inflow increased; Helicine arteries dilated; Due to arterial inflow > venous outflow
• NOTE: Erection PSNS ® Ejaculation SNS

1. Viagra
2. Vacuum pump + constriction rings: pump air out so blood enters penis, then remove pump and apply constriction ring (for < 30 mins)
3. PGE1 ® ­ cAMP ® injected into side of penis (cavernosa communicate)
4. Medicated urethral System of Administration: MUSE (alprostadil)
5. Cream inserted into urethra
6. Uprema (sublingual apomorphin): increases desire and arousal [apomorphin: for PD]
7. Penile prosthesis (3rd line): 3-piece penile prosthesis in which the pump alone sits in the scrotum and the reservoir lies in the lower abdominal wall; only for desperate cases, transsexuals

• Laser Tx for detached retina or vitreous haemorrhage should be warned to avoid sexual activity
• Morning/ Nocturnal erection: need oxygenated inside penis to maintain its health
• Try not advise Pt's to abstain from sex
• Need to be able to climb 2 flights of stairs (exercise tolerance) in order to have sex