Introduction to Sexual Medicine

Figure 1-1.

Small sculpture of a sexual scene [Reprinted from: https://commons.wikimedia.org/wiki/Category:Ancient_Egyptian_erotic_art#/media/File:Egypt-sex.jpg with permission from Creative Commons].

Figure 1-2.

Turin erotic papyrus (damaged) [Reprinted from: https://commons.wikimedia.org/wiki/File:Turin_Erotic_Papyrus.jpg ].

One of the first sex manuals in history is the Kama Sutra, written in India, in second century BC. Techniques of sexual pleasure enhancement including positions are fully explained including the spiritual aspects. Some of the positions were carved inside the Mukteswar Temple in Bhubaneswar, India (Figure 1.3).

Figure 1-3.

Kama Sutra [Reprinted from: https://commons.wikimedia.org/wiki/File:Mukteswar_temple.jpg with permission from Creative Commons].

In 1896, Havelock Ellis, an English physician (Figure 1.4), published “Studies in the Psychology of Sex ,” discussing normal and abnormal sexuality. Around the same time, in 1898, Richard von Krafft-Ebing, a German psychiatrist (Figure 1.5), published in Latin a book called “Psychopathia Sexualis ” (Figure 1.6), which is the first modern text on sexual disorders including the paraphilias. By 1918, Sigmund Freud (Figure 1.7), the founder of psychoanalysis, considered sexuality central to his psychoanalytic theory.

Figure 1-4.

Havelock Ellis [Reprinted from: https://commons.wikimedia.org/wiki/File:Havelock_Ellis_cph.3b08675.jpg].

Figure 1-5.

Richard von Krafft-Ebing [Reprinted from: https://en.wikipedia.org/wiki/Richard_von_Krafft-Ebing#/media/File:Richard_v._Krafft-Ebing.jpg ].

Figure 1-6.

Krafft-Ebing’s book [Reprinted from: https://en.wikipedia.org/wiki/Richard_von_Krafft-Ebing#/media/File:Krafft-Ebing_Psychopathia_sexualis_1886.jpg with permission from © Foto H.-P. Haack (H.-P. Haack)].

Figure 1-7.

Sigmund Freud [Reprinted from: https://commons.wikimedia.org/wiki/File:Sigmund_Freud_LIFE.jpg].

Early in the twentieth century, German physician Magnus Hirschfeld (Figure 1.8) founded the first sex-research institute in Germany. He conducted the first large-scale sex survey, collecting data from 10,000 men and women. He also initiated the first journal for publishing the results of sex studies. The Nazis destroyed most of his materials during World War II. In the early 1930s, American anthropologist Margaret Mead and British anthropologist Bronislav Malinowsky began studying sexual behavior in different cultures [3].

Figure 1-8.

Magnus Hirschfeld [Reprinted from: https://wellcomeimages.org/indexplus/email/299273.html with permission from Creative Commons].

In the USA, Alfred Kinsey (Figure 1.9) published a survey of 18,000 subjects regarding sexual behaviors in 1947. William Masters and Virginia Johnson followed this survey with rigorous lab study of sexual encounters. Masters and Johnson developed key concepts in sexual medicine such the sexual response cycle, and developed an effective treatment technique for sexual dysfunction named sex therapy . Helen Singer Kaplan followed with a major expansion on training sex therapists, including desire in the sexual response cycle, and examining premature ejaculation from psychological as well as behavioral angles.

Figure 1-9.

Alfred Kinsey [Reprinted from: https://commons.wikimedia.org/wiki/File:Alfred_Kinsey_1955.jpg].

In 1981, Ronald Virag (Figure 1.10) discovered during a surgical procedure on the penis that papaverine caused an erection when injected into the penis. In 1983, Giles Brindley (Figure 1.11) gave his notorious AUA Lecture in Las Vegas when he had previously injected himself with a vasodilator, identified as phentolamine in some accounts and papaverine in others. The self-injection became later one of the most reliable interventions to produce an erection.

Figure 1-10.

Ronald Virag [Reprinted from: https://commons.wikimedia.org/wiki/File:Dr._Ronald_Virag,_working.jpg with permission from Creative Commons].

Figure 1-11.

Giles Brindley [Reprinted from Goldstein, I.R.W.I.N., The Hour Lecture That Changed Sexual Medicine—The Giles Brindley Injection Story. Journal of Sexual Medicine 2012; 9(2): 337-342. with permission from Elsevier].

The National Health and Social Life Survey (NHSLS ), also known as the Chicago Study or Chicago Survey, is a landmark epidemiological study of sexual function and dysfunction examining randomly selected 3432 subjects who underwent face-to-face surveys. This well-designed survey revealed that about 43% of women and 31% of men suffer from sexual dysfunction.

The most significant breakthrough was the identification of nitric oxide as the principal neurotransmitter responsible for the relaxation of the corpus cavernosum smooth muscle, by Louis Ignarro, Ph.D. in 1997, as a result of 2 decades of research. This discovery enabled the development of oral pharmacological agents for the treatment of erectile dysfunction . Dr. Ignarro (Figure 1.12) was awarded the Nobel Prize for this momentous discovery in 1998 [4].

Figure 1-12.

Louis Ignarro, Ph.D. [Reprinted from: https://sv.wikipedia.org/wiki/Fil:Louis_J._Ignarro_portrait.jpg].

The late 1990s brought more focus on women’s sexual health, largely due to the efforts of Jennifer and Laura Berman, who were originally mentored by Irwin Goldstein at Boston University [5]. Rosemary Basson introduced the circular model of the sexual response cycle in women where arousal could overlap with desire. The current state of the field is an exciting one, with a plethora of biochemical and physical interventions, in addition to well-tested and effective psychosocial ones.

Classifications of Sexual Dysfunctions

There are several major classification systems of both male and female sexual dysfunction. One of the most common classifications is in the ICD-10 : The International Classification of Diseases, 10th edition, which was published by the World Health Organization in 1992. The ICD-11 is expected to be published in 2017. The ICD codes disorders as either organic (physiologic) or non-organic (psychosomatic). Non-organic disorders may be intermittent and occur on a case-by-case basis. For example, a male who complains of erectile dysfunction (ED ) but has a normal morning erection has a non-organic rather than organic cause of ED since there is no physiologic dysfunction. Non-organic disorders are those such as sexual aversion, sexual desire disorder, non-organic vaginismus, non-organic dyspareunia, and excessive sexual drive. Organic disorders have a physiological/somatic basis and include ED, vaginismus, and dyspareunia.

Another widely known system of classification for sexual dysfunction is the DSM-5 : The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The DSM has been widely used by the American Psychiatric Association to classify sexual disorders as well as other types of psychological conditions. The most recent edition has been published in May 2013 and contains several important changes including the criterion that nearly all sexual dysfunction diagnoses now require a minimum duration of 6 months as well as a frequency of 75–100% of the time. Additionally, many disorders are now listed as gender specific, and several of the female disorders are consolidated into single diagnoses. Additionally, a new group of criteria called “associated features” is introduced, dividing potential contributing factors of sexual dysfunction into five categories: (1) partner factors, (2) relationship factors, (3) individual vulnerability factors, (4) cultural factors, and (5) medical factors. Several disorders are deleted from the DSM such as male dyspareunia or sexual aversion disorder. Duration and frequency requirements are implemented to increase the validity and clinical usefulness of the manual to the psychiatric community [6].

Women and Sexual Medicine

In women , the most common cause of sexual dysfunction is vaginal dryness or failure of lubrication. Approximately 8–28% of sexually active women report lubrication difficulties, which can be attributed to pathologic/organic causes, psychogenic/non-organic causes, or estrogen deficiency [8].

Women’s sexual function is a complex neuromuscular process. Along with hormonal changes, arousal is marked by blood volume and pressure changes in the clitoris and labia (Figures. 1.13 and 1.14). Irregularities in various psychological, hormonal, physiological, and environmental factors can account for female sexual dysfunction in a number of ways. Female sexual dysfunction can be characterized by sexual pain disorders, desire/arousal disorders, and orgasmic disorders [9].

Figure 1-13.

Female sexual and reproductive organs [Reprinted from https://commons.wikimedia.org/wiki/File:Blausen_0400_FemaleReproSystem_02.png with permission from Creative Commons].

Figure 1-14.

External female sexual organs [Reprinted from: https://commons.wikimedia.org/wiki/File:Figure_28_02_02.jpg with permission from Creative Commons].

The DSM-5 has eliminated and condensed the diagnoses of female sexual dysfunction from five disorders of desire, arousal, orgasm, vaginismus, and dyspareunia to three disorders [10]. Female hypoactive desire disorder is combined with arousal disorder to form female sexual interest/arousal disorder. This diagnosis is even less contingent upon physical stimuli and is characterized by persistent deficiency of sexual thoughts or desire for sexual activity [6]. Orgasmic disorder has remained unchanged. Vaginismus and dyspareunia are merged into genito-pelvic pain/penetration disorder, as it has been decided that the two disorders could not be reliably differentiated due to the lack of empirical evidence of vaginal muscle spasm and the overlap of fear of penetration [6].

There is epidemiological data indicating that 40–45% of women have at least one form of sexual dysfunction. The prevalence of women expressing low levels of sexual interest increases with age, with about 10% of women up to age 49, 22% of those ages 50–65, and 74% of 66–74-year-olds expressing low levels of desire [11].

Such dysfunctions may be a lifelong problem or acquired later in life. Risk factors for decreased lubricative function, anorgasmia, and other sexual disorders include but are not limited to age, sociocultural factors, alcohol use, prescription and non-prescription drug usage. Other factors that increase the risk of sexual dysfunction include medical conditions such as hypertension, certain hormone imbalances, urinary incontinence, cardiovascular disease, diabetes mellitus, and depression [11].

Female sexual interest/arousal disorder is described as significantly reduced interest in sexual activity, reduced or absent erotic thoughts, or reduced initiation or receptivity to sexual activity. As many as 75–100% of these women may experience diminished pleasure during sexual encounters, absent/reduced sexual arousal in response to internal or external cues, and reduced genital sensations during 75–100% of sexual encounters. Different cases have reported various duration of symptoms. Older women generally report less distress about low sexual desire than younger women, as sexual desire also decreases with age [11].

Female orgasmic disorder constitutes a marked delay, infrequency, or absence of orgasm, or it can be defined as a reduced intensity of orgasmic sensations. Orgasmic disorder must be accompanied by clinically significant distress and cannot be justified by significant interpersonal or contextual factors. Approximately 10% of women do not experience orgasm throughout their lifetime. Reported prevalence rates for female orgasmic disorder range widely from 10 to 42%, though only a small proportion of women also report associated distress [10].

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