Medical brain notes 42

  An estimated 35% to 45% of women perceive they  A  have some type of sexual problem—most com-monly low sexual desire. Illness, medical and sur-gical treatment, lack of knowledge to manage this life  experience, and emotional and physical stresses contribute to the frequency and severity of sexual problems. Physicians should be able to identify sexual disorders and know whether to offer treatment or refer patients to a specialist.   Determinants of healthy sexuality are complex and multifactorial. Intrapersonal factors include the sense of one’s self as a sexual being, one’s overall health status, a general perception of well-being, and the quality of an individual’s previous sexual experiences. For partnered individuals, this same list applies to the partner. Inter-personal aspects include the duration and overall quality of the relationship, communication styles, and the number and type of ongoing life events and stressors. Examples of generally “positive” li...

  SEXUAL IDENTITY   At the most basic level, the experience of sexuality begins with an individual’s genotype and phenotype. From this basic biologic underpinning, children develop a gender identity during early childhood. Eventually, each individ-ual develops a sense of self as a sexual being and a sexual orientation. Each of these latter components is fluid and can vary over time and with particular circumstances. For example, many individuals who consider themselves het-erosexual periodically engage in sexual encounters with same-sex partners.

  HUMAN SEXUAL RESPONSE   In evaluating sexual problems, it is useful to consider the mechanisms of sexual response in women. Sexual function and dysfunction are perhaps the supreme exam-ples of a necessary blending of mind and body. This inter-action is crucial to the understanding of the assessment and management of sexual problems. The dualistic ap-proach common to more traditional models of sexual response limits the understanding of female sexuality inso-far as it suggests that dysfunction is either psychologic or biologic or psychologic plus biologic. Newer approaches are more holistic in their representations of female sexual response.   Traditional Model   The traditional Masters and Johnson and Kaplan models of the human sexual response cycle are being replaced by intimacy-based sexual response models that take other factors into consideration. The traditional cycle depicts a linear sequence of events: desire, arousal, plateau of constant high arousal, peak ...

  SEXUAL DYSFUNCTION   There is uncertainty as to what exactly constitutes a sexual disorder. The definition of “sexual disorder” is made more complex because what is considered “disordered” varies with time and culture. The World Health Organization’s  International Statistical Classification of Diseases and Related Problems  (ICD-10) suggests that sexual dysfunctions are“the various ways in which an individual is unable to partic-ipate in a sexual relationship the way he or she would wish.” Table 47.1 lists the categories of sexual dysfunction as rec-ognized by both the  Diagnostic and Statistical Manual ofMental Disorders: DSM-IV-TR,  which limits its definitions tomental disorders, and the 1998 consensus committee spon-sored by the American Foundation of Urological Disease, which is also limited insofar as it conceptualizes sexual response in women as discrete linear experiences, as in the formerly accepted model of female sexual response already discus...

  FACTORS AFFECTING SEXUALITY   The relationship between an overall sense of personal well-being and sexual function is complex. Approximately one-third of women presenting with sexual dysfunction are clinically depressed. Among individuals in whom depression has already been diagnosed, the type and progress of ongo-ing therapy and prescribed medication should be noted.   The commonly prescribed selective serotonin-reuptake inhibitors, such as fluoxetine, paroxetine, sertra-line, and escitalopram, can be associated with decreased sexual desire. The clinical observation that is helpful when evaluating the contribution of medications to female sexual dysfunction is that antidepressants that activate dopaminer-gic, (central) noradrenergic, and 5-hydroxytriptamine (5-HT) 1A and 5-HT2C receptors may augment sexual response, whereas those that activate other 5-HT receptors, prolactin, and gamma-amino-butyric acid reduce sexual response. The medications least likely to interfere...

  MANAGEMENT   A woman’s sexuality is influenced by her health and emotional well-being; likewise, healthy sexual function-ing promotes physical and emotional well-being. How-ever, studies suggest that fewer than one-half of patients’ sexual concerns are recognized by their physicians. The obstetrician-gynecologist has a paramount role in assessing sexual function and managing sexual dysfunc-tion to ensure the well-being of his or her patients. Beginning with screening a patient for sexual dysfunc-tion, taking her history, and assessing sexual dysfunction risk factors, the physician establishes a diagnosis if dys-function is present and treats the patient or refers her for treatment, as appropriate.   Screening for Sexual Dysfunction   Questioning patients about their sexual desire, especially about responsive desire and the components of arousal, can point to management options about which patients and  their partners can be counseled.     Simply prov...