PANCE Blueprint Psychiatry (6%)

Human sexuality (PEARLS)

The DSM-5 has two diagnostic criteria that fall into the category of human sexuality (as defined by the PANCE/PANRE Blueprint) - Sexual dysfunction and Paraphilic disorders. I have also included a table summarizing sexual orientation and gender identity.

Sexual dysfunctions DSM-5

To fulfill the DSM-5 criteria of 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.

Delayed ejaculation Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity and without the individual desiring delay for a minimum duration of approximately 6 months

  • Marked delay in ejaculation
  • Marked infrequency or absence of ejaculation

TX: There isn’t an approved drug treatment for delayed ejaculation “off-label” treatments may include:

  • Testosterone, buspirone, amantadine, oxytocin, and cabergoline
  • Other treatments include cognitive-behavioral therapy, masturbatory retraining, etc.

References: UpToDate

Erectile disorder
Patient will present as → a 34-year-old heterosexual male who presents to your clinic for concerns regarding erectile dysfunction. He works for Facebook and admits to working long hours in a very stressful environment. He reports having morning and night-time erections. The problem started approximately one year ago and has had a significant impact on his relationships. Often times he is unable to obtain an erection and when he does his penis is often flaccid and it is difficult to achieve penetration. This has resulted in significant distress and he has almost completely stopped dating.

At least one of the three following symptoms must be experienced on almost all or all (approximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.

  • Marked difficulty in obtaining an erection during sexual activity
  • Marked difficulty in maintaining an erection until the completion of sexual activity
  • Marked decrease in erectile rigidity

TX: Treatment options include oral phosphodiesterase inhibitors - These drugs include sildenafil (Viagra), vardenafil, avanafil, and tadalafil

  • Intraurethral or intracavernosal prostaglandins, vacuum erection devices, and surgical implants

References: Merck Manual · UpToDate

Female orgasmic disorder

Presence of either of the following symptoms and experienced on almost all or all (ap­proximately 75%-100%) occasions of sexual activity for a minimum duration of approximately 6 months.

  • Marked delay in, marked infrequency of, or absence of orgasm
  • Markedly reduced intensity of orgasmic sensations

TX: First-line treatment of female orgasmic disorders is directed masturbation, which involves a series of prescribed exercises

  • Sex therapy, cognitive-behavioral therapy

References: Merck Manual · UpToDate

Female sexual interest/arousal disorder
Patient will present as → a 33-year-old woman with a chief complaint of trouble having intercourse. She is completely disinterested in sex and she is not receptive to her partner’s attempts to initiate foreplay. She reports that when they do have sex she never achieves orgasm. This is affecting her current relationship with her boyfriend.

Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following for a minimum duration of approximately 6 months

  • Absent/reduced interest in sexual activity
  • Absent/reduced sexual/erotic thoughts or fantasies
  • No/reduced initiation of sexual activity, and typically unreceptive to a partner’s at­tempts to initiate
  • Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters
  • Absent/reduced sexual interest/arousal in response to any internal or external sex­ual/erotic cues (e.g., written, verbal, visual)
  • Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational con­ texts or, if generalized, in all contexts)

TX: Education about sexual anatomy and function

  • Effective sexual stimuli may include nonphysical, physical nongenital, and nonpenetrative genital stimulation
  • Cognitive-behavioral therapy
  • Hormonal therapy - testosterone, etc.

References: Merck Manual · UpToDate

Genito-pelvic pain/penetration disorder

Persistent or recurrent difficulties with one (or more) of the following for a minimum duration of approximately 6 months

  • Vaginal penetration during intercourse
  • Marked vulvovaginal or pelvic pain  or penetration attempts
  • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration
  • Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration

TX: Treatment of cause when possible (eg, topical estrogen for atrophic vaginitis)

  • Education about chronic pain and its effects on sexuality
  • Psychologic therapies
  • Pelvic floor physical therapy
  • Progressive desensitization

References: Merck Manual · UpToDate

Male hypoactive sexual desire disorder
Patient will present as → a 53-year-old male complaining of a lack of desire for sex with his wife causing him marked distress for the past year. His wife has been very hurt by his lack of response to her advances and he reports that this is having a significant strain on their relationship. Prior to this, he was interested in sex and he and his wife would have intercourse 1-2x per month. He is very active and continues to compete in triathlons. He has no significant past medical history.

Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity for a minimum duration of approximately 6 months

  • The judgment of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and socio­ cultural contexts of the individual’s life

TX: Common treatments for HSDD include testosterone therapy and other medications, as well as sex therapy

References: Merck Manual · UpToDate

Premature (early) ejaculation
Patient will present as → a 24-year-old, healthy heterosexual male who is concerned about early ejaculation. He has had two sexual partners and has experienced this problem with both partners. He has a new girlfriend and this is his first long-term relationship and he is very concerned. He reports that “the first time we made love I was nervous and it was all over very quickly. She was very understanding and although a little disappointed, she gave me the impression that we just needed to get used to each other.” Unfortunately, this happened consistently over the next few weeks. They spoke about the problem, and he told her that he had never been able to go for more than five minutes. “I simply cannot control my ejaculation, and although some love-making sessions last longer than others, the problem has been with me from the first time that I made love.”

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

  • Must be experienced on almost all or all occasions (approximately 75%-100%) of partnered sexual activity and without the individual desiring delay for a minimum duration of approximately 6 months.

TX: SSRIs are first-line treatment

  • Available agents and dosages include paroxetine (10 to 40 mg/day), sertraline (50 to 200 mg/day), fluoxetine (20 to 40 mg/day), citalopram (20 to 40 mg/day), and escitalopram (10 to 20 mg/day)
  • Topical anesthetics, sex therapy, and tricyclic antidepressants

References: Merck Manual · UpToDate

Substance/medication-induced sexual dysfunction
Patient will present as → a 55-year-old male who is on fluoxetine for treatment of major depressive disorder. He reports a significant delay in ejaculation. He is happily married with two children. He continues to desire intercourse and has no problem attaining an erection but since starting the SSRI he often takes 30-40 minutes to achieve orgasm and sometimes is unable to achieve orgasm during both oral and/or penetrative sex.

Substance-induced sexual dysfunction refers to a condition in both men and women in which patients have difficulties with sexual desire, arousal, and/or orgasm due to a side effect of certain medications (legal or illicit)

TX: Remove (or adjust dosage of) the offending agent

Paraphilic disorders DSM-5
Voyeuristic disorder
Patient will present as → a 20-year-old male college student was reported by others for spying through the windows of his fellow female dormmates. 

Sexual gratification attained by observing unsuspecting individuals undressing or naked

TX: If patients have committed a sexual offense, treat with psychotherapy and SSRIs first

  • If additional treatment is needed and if informed consent is obtained, treat with antiandrogen drugs

References: Merck Manual

Exhibitionistic disorder
Patient will present as → a 23-year-old male who goes to city park during the summer months in an overcoat. He enjoys walking around the park exposing his genitals to strangers. He then runs away so as to avoid getting caught.

Sexual gratification attained by exposing genitals to unsuspecting strangers

TX: If patients have committed a sexual offense, treat with psychotherapy and SSRIs first

  • If additional treatment is needed and if informed consent is obtained, antiandrogen drugs may be considered

References: Merck Manual

Frotteuristic disorder
Patient will present as → a 29-year-old male who was brought in by his wife and older brother. According to them, the patient has a desire to rub his privet area against other people, when the opposing person is not looking. He has done this action in their home, and to his wife when she is doing the dishes, or even cooking dinner and began to rub against his brother when he would be helping his with things around the house.

Sexual gratification attained by touching or rubbing against a nonconsenting individual

TX: Treating frotteurism usually includes psychotherapy and behavior therapy

  • Psychotherapy focuses on identifying triggers for frotteuristic behavior and coming up with strategies to redirect thoughts and feelings
Sexual masochism disorder
Patient will present as → a 23-year-old male who concerned that his behavior has resulted in his inability to maintain a relationship. He reveals that he requires his partners to strangle him and humiliate him in order for him to achieve and maintain an erection.

Sexual gratification in response to undergoing humiliation, bondage, or suffering

  • Asphyxiophilia is considered a subtype of sexual masochism disorder

TX: Treatment for sexual masochistic disorder typically involves psychotherapy and medication that can reduce sex drive

  • Antidepressant medications may also be used to reduce sex drive

References: Merck Manual

Sexual sadism disorder
Patient will present as → a 42-year-old white man seeking help for depression and suicidal ideations. In a detailed interview, the patient reveals his involvement in sexual acts that make him guilty. He reports that he and his girlfriend of the last two years had been involved in cutting and drawing blood from each other’s bodies while engaging in sexual activity. The two also drink each other’s blood while involved in these sexual activities, and he reports that cutting and drinking his partner’s blood is the only way that he can reach orgasm. On physical exam, you note numerous scars on his arms and chest that are very deep and in different stages of healing.

Sexual gratification in response to inflicting humiliation, bondage, or suffering

TX: Sexually sadistic interests do not require treatment unless causing significant impairment or distress, or harm to self or another has occurred

  • Psychotherapy
  • Antidepressants (SSRIs) and testosterone blockers (anti-androgens and GnRH analogs)

References: Merck Manual

Fetishistic disorder
Patient will present as → a female brings her 29-year-old boyfriend to a couples therapist because she is uncomfortable with his behavior. She found him clutching her feet during intercourse, and noticed that he insists on being able to see her feet while they engage in sexual acts.

Recurrent and intense sexual urges, fantasies, or behaviors that involve the use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by clinically significant distress or impairment

TX: Treatment of fetishistic disorder may include psychotherapy, drugs, or both

  • Selective serotonin reuptake inhibitors have been used with limited success in some patients who request treatment

References: Merck Manual

Pedophilic disorder
Patient will present as → a 33-year-old male gymnastics teacher insists that all his students take a shower after class. He supervises the children showering and becomes sexually aroused.

Repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children (generally 13 years or younger), and either act on these urges or experiences clinically significant distress or impairment

TX: In the US, the treatment of choice for pedophilia is IM medroxyprogesterone acetate

  • The GnRH agonist leuprolide, which reduces pituitary production of LH and FSH and thus reduces testosterone production, is also an option and requires less frequent IM injections than medroxyprogesterone.

References: Merck Manual

Transvestic disorder Defined as a condition in which there is persistent (at least 6 months), recurrent, and intense sexual arousal from wearing clothes associated with the opposite gender as evidenced by fantasies, urges, or behaviors

TX: Most cross-dressers do not present for treatment. Those who do are usually brought in by an unhappy spouse, referred by courts, or self-referred out of concern about experiencing negative social and employment consequences

  • Social and support groups for men who cross-dress are often very helpful
  • Psychotherapy, when indicated, is aimed at self-acceptance, family therapy, and modulating risky behaviors.
  • No drugs are reliably effective, although SSRIs have been tried and occasionally are beneficial in patients with a substantial obsessive-compulsive component to their presentation.

References: Merck Manual

Sexual orientation and gender identity
Affirmed gender When one's gender identity is validated by others as authentic
Agender A person who identifies as genderless or outside the gender continuum
Cisgender Not transgender; a person whose gender identity and/or expression aligns with their sex assigned at birth
Crossdressing Wearing clothes typically associated with another gender; the term transvestite can be considered pejorative and should not be used
Cultural humility Concept of not projecting one's own personal experiences and preconceptions of identity onto the experiences and identities of others
Differences of sex development Congenital conditions characterized by nuanced chromosomal, gonadal, or anatomic sex development (e.g., congenital adrenal hyperplasia, androgen insensitivity syndrome, Turner syndrome); not a universally accepted term; also called disorders of sex development or intersex
Gender The societal perception of maleness or femaleness
Genderqueer Umbrella term for a broad range of identities along or outside the gender continuum; also called gender nonbinary
Gender diverse* A general term describing gender behaviors, expressions, or identities that are not congruent with those culturally assigned at birth; may include transgender, nonbinary, genderqueer, gender fluid, or non-cisgender identities and may be more dynamic and less stigmatizing than prior terminology (e.g., gender nonconforming); this term is not used as a clinical diagnosis
Gender dysphoria Distress or impairment resulting from incongruence between one's experienced or expressed gender and sex assigned at birth; DSM-5 criteria for adults include at least six months of distress or problems functioning due to at least two of the following:

  • A marked incongruence between one's experienced or expressed gender and primary and/or secondary sex characteristics
  • Strong desire to be rid of one's primary and/or secondary sex characteristics
  • Strong desire for the primary and/or secondary sex characteristics of the other gender
  • Strong desire to be of the other gender
  • Strong desire to be treated as the other gender
  • A strong conviction that one has the typical feelings and reactions of the other gender
Gender expression External display of gender identity through appearance (e.g., clothing, hairstyle), behavior, voice, or interests
Gender identity Internalized sense of self as being male, female, or elsewhere along or outside the gender continuum; some persons have complex identities and may identify as agender, gender nonbinary, genderqueer, or gender-fluid
Gender identity disorder Diagnosis related to gender dysphoria or gender incongruence in earlier versions of the DSM and ICD
Gender incongruence* General term describing a difference between gender identity and/or expression and designated sex; an ICD-11 diagnosis that does not require a mental health diagnosis
Sex Maleness or femaleness as it relates to sex chromosomes, gonads, genitalia, secondary sex characteristics, and relative levels of sex hormones; these biologic determinants may not necessarily be consistent; sex assigned at birth is typically based on genital anatomy
Sexual orientation A term describing an enduring physical and emotional attraction to another group; sexual orientation is distinct from gender identity and is defined by the individual
They/them Neutral pronouns preferred by some transgender persons
Transgender* General term used to describe persons whose gender identity or expression differs from their sex assigned at birth
Transgender female A transgender person designated as male at birth
Transgender male A transgender person designated as female at birth
Transfeminine Nonbinary term used to describe a feminine spectrum of gender identity
Transmasculine Nonbinary term used to describe a masculine spectrum of gender identity
Transphobia Prejudicial attitudes about persons who are not cisgender
Transsexual Historical term for transgender persons seeking medical or surgical therapy to affirm their gender
*—The terms gender diverse, gender incongruence, and transgender do not necessarily imply gender dysphoria.
osmosis Osmosis
Psychosexual stages of development (overview)

The psychodynamic stages of development were described by Freud, where he described that sex instinct was not a single instinct, but rather many. He identified erogenous zones, like the oral, anal and genital regions, and associated them with providing pleasure through stimulation. Furthermore, these zones play a role in determining adult personality by representing conflicts. He described these conflicts in a sequential manner starting with the oral stage, then progressing to the anal, phallic, latency and genital stages.

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