žPart of medicine that deals with conditions that influence the sexual life of patients. žIt’s interdisciplinary and integrates knowledge of several medical specializations. žSexology isn’t uniform throughout the World and there are countries where it doesn’t exist as an integrated discipline. žPsychiatry žPsychology žUrology žGynecology žEndocrinology ž ž žSexual dysfunctions (not caused by organic disorder or disease) žGender identity disorders žDisorders of sexual preference žPsychological and behavioral disorders associated with sexual development and orientation žOrganic sexual disorders (the coordination of treatment) žFertility problems žSexual crimes ›Medical examination of the offender ›Care of the victim › žOther problems linked to the human sexuality žInterview with the patient žClinical examination žLaboratory analyses (blood, sperm...) žPhalopletysmografy/vulvopletysmografy ž žOther specific methods if needed žOrganic(traumas, illness, congenital defects…) ž žNot organic ›Sexual dysfunction covers the various ways in which an individual is unable to participate in a sexual relationship as he or she would wish, the preferred sexual object and activities are normal. ž žSexual desire žSexual excitement (with physiological reactions) žIntercourse žOrgasm žResolution ž sexualresponse žLack or loss of sexual desire žSexual aversion žLack of sexual enjoyment žExcessive sexual drive › Sex dependence ›Obsessive sexual behaviour (often with the intention of reducing stress or anxiety) ž ž žFailure of genital response ›Erectile dysfunction in males ›Insufficient lubrication in females žInhibited orgasm (male, female) ›Primary x secondary ›Generalized (total) x selective (situational) › žPremature ejaculation ›The inability to control ejaculation sufficiently for both partners to enjoy sexual interaction. ž žDelayed ejaculation ž žNonorganic vaginism ›Spasm of the pelvic floor muscles that surround the vagina, causing occlusion of the vaginal opening. Penile entry is either impossible or painful. žNonorganic dyspareunia (pain during sexual intercourse) ›occurs in both women and men. žThe female orgasm isn’t indispensable for the fertilization and it isn’t present in other mammals. ž5-10% of women in the population never achieve orgasm žOrgasmic capacity depends on age and is best between 30 and 35 years žThe present generation of women have better capability of achienving orgasm than had generations of their grandmothers ž žOrganic x non-organic žGeneralized x situational ž žTreatment: pharmacological, psychotherapeutic žMedications: sildenafil, tadalafil, vardenafil (phosphodiesterase type 5 inhibitors) žThe inability to control ejaculation sufficiently for both partners to enjoy sexual interaction. žIt even exists “ejaculation ante portas” ž“normal” intercourse duration : 3-7minutes žAn intercourse under 1 minute is usually problematic ž žTreatment: psychotherapy, exercises, medicines (antidepressants with serotonergic effects) žAlso: paraphilias ž žTerms not used any longer (offensive) ›sexual deviation ›perversion ž žCharacteristics common to all human beings žCulturally determined characteristics žIndividual characteristics žSexual activities can be considered normal if: ›Don’t cause physical or psychological harm to anyone, ›Are acceptable to all participants, who are mature enough and not consanguineous relative. ž žHumans don’t have a simple sexual instinct žThey possess a system of sexual motivation žIt’s a hierarchical system consisting of partial sexual activations žAfter one activity has been completed, another can begin žIt’s formed during the intrauterine life and is usually completed within the first 3 years of life, but remains still. žIt awakens at the beginning of puberty žAttractivity phase (a stage when general sexual interest is expressed) žProceptivity phase (directed towards a specific person) ›„Gender signals“ ›Flirting ›Nonverbal contact ›Verbal contact ›Approaching and “accidental” tactile contacts žReceptive phase ž žGender identity disorders ž žDisorders of sexual orientation ž žDisorders of sexual activity žChange in the sexual motivation system ž žThe whole proceptivity phase is altered ›Not only the sexual practices! ž žRelationships with persons of the same sex or of inappropriate age or preference for not living objects ž žRelations with persons of appropriate age but of the same sex ž žIt’s not considered mental disorder since the 70’s. ž žIt’s innate, permanent and unalterable state of the sexual motivation system ž žIt may be a social, political, moral and religious issue, but not medical any longer. ž žA sexual preference for children, boys or girls or both, usually of prepubertal or early pubertal age. žTypically between 5 and 12 years žFascination with the child’s behaviour and appearance žHeterosexual paedophilia – preference for girls usually between 5 – 11 years, with usually close relationship žHomosexual paedophilia – preference for boys around 12 years, more aggressive activities, directed more towards achieving orgasm žExperimentally, sexual arousal can be achieved with the pictures of prepubertal girls in most heterosexual men. Therefore all societies have to determine the age of consent and protect their children. ž žInterest in pubertal girls ž ž ž žsexual preference of adults for mid-to-late adolescent boys, generally ages 15 to 19. žReliance on some non-living object as an indispensable stimulus for sexual arousal and sexual gratification. Many fetishes are extensions of the human body, such as articles of clothing or footwear. Other common examples are characterized by some particular texture such as rubber, plastic or leather. ž žFetish objects vary in their importance to the individual. In some cases they simply serve to enhance sexual excitement achieved in ordinary ways (e.g. having the partner wear a particular garment). ž ž ž žThe preferred sexual activity is masturbation with the preferred objects žSometimes it’s possible to introduce the object to the couple activities ž žThe occurrence in women is very rare. ž shoe%20fetish ž žAlso transvestic fetishism žThe wearing of clothes of the opposite sex principally to obtain sexual excitement and to create the appearance of a person of the opposite sex. žClear association with sexual arousal and the strong desire to remove the clothing once orgasm occurs and sexual arousal declines. žThere is no doubt about own gender žIt’s exclusively men’s condition cover10 ž žNecrophilia- dead bodies žZoophilia - animals žPyrophilia - fire žMysophilia - dirt žGerontophilia – old people žStatuophilia - statues ž žAll are rare conditions žThe object of desire is normal – an adult person of the opposite sex ž žAlteration of achieving sexual excitation and how this excitation is resolved (satisfied) ž žVoyeurism žExhibitionism žToucherism žFrotteurism žPathological sexual aggressivity žSadism, sadomasochism žOther and combined (multiple) žFr. voir = to see or look žA recurrent or persistent tendency to look at people engaging in sexual or intimate behaviour such as undressing. žThis is carried out without the observed people being aware, and usually leads to sexual excitement and masturbation. žThis is preferres behaviour even if there is possibility to have a sexual partner. žLat. exhibere = to exhibit ž žA recurrent or persistent tendency to expose the genitalia to strangers (usually of the opposite sex) or to people in public places, without inviting or intending closer contact. žThere is usually sexual excitement at the time of the exposure and the act is commonly followed by masturbation. žIt’s the most common disorder in this group ž ž žThe excitement is achieved by breaking the resistance of an unknown woman, who is attacked and whose cooperation is reduced to minimum žPredatory behaviour žThe aggressor attacks a surprised victim, who is not expecting anything, knocks her down a tries to rape her. žNo previous attempt of contact is usually present. žThe excitation is achieved by making immobile the object of sexual desire žIn this group there are many sexual murderers ›But the primary intention is not to kill žThis type of murderers forms only a small subgroup among all murderers, but enjoy a large public attention ž žA preference for sexual activity which involves the infliction of pain or humiliation, or bondage. žIf the subject prefers to be the recipient of such stimulation this is called masochism; if the provider, sadism. žOften an individual obtains sexual excitement from both sadistic and masochistic activities. sm ž žA problematic group of patients ›Enormous stigma ›Fear of attending medical care ›Their sexuality is often suppressed to avoid unacceptable sexual activities › žIt’s not possible to change sexual motivation ž žAccept one’s own sexuality žIdentify the stimuli that could initiate the pathological sexual behaviour žForm brakes and safety behaviours žEngage in couple life if possible žUse other ways of reducing sexual arousal ž ž žPsychotherapy ž žDrug treatment (to reduce sexual desire) ›Antidepressants ›Antipsychotics ›Antiandrogens ž žSurgical treatment (pulpectomy, castration – ethical controversy) žAt present the term GENDER DYSPHORIA is used žThe ICD-10 includes the term transsexualism ž žThe ICD-11 presents with the term GENDER INCONGRUENCE žSex versus gender žThe gender is assigned at birth based on the visual aspect žThat leads to expectations of a certain type of behaviors žA real gender identity stabilises much later žIn adults the prevalence may be up to 1:200 (0,5%) (Conron et al., 2012) ž ž žBased on common experience, in Europe, North America and Asia the numbers of people seeking help for gender dysphoria increases. ž žIn the West significantly increasing numbers of adolescent natal girls have been noticed Source: Národní registr hrazených zdravotních služeb ž žTwo significantly different conditions can be defined: ž ž ›GD in pre-pubertal children › ›GD in pubertal, adolescent and adult people › ž ž ž”Wait and watch“ approach ž žThe subjective experience of gender should be taken in account including name and forms of address ž žNo hormonal or surgery treatment are recommended at this stage. ž žOnly a proportion of these children, albeit large, will fullfil complete criteria for GD in adulthood ž žIf GD persists after onset of puberty, there is little or no chance that it will change later. ž žIf GD worsens with the onset of puberty, it is a strong diagnostic feature. ž žMany people with GD try to “fit” their prescribed gender at the beginning of puberty, they feel strong distress and inappropriateness and they realize due to this effort that they simply cannot fit. ž ž žThe care must be interdisciplinary. ž žThe main role plays a sexologist/psychiatrist who coordinates the care ž žA psychologist is an important member of the team as well as an endocrinologist, gynecologist, GP or pediatrician. ž žPsychotherapy is very important and should aim at adjustment issues, relationships and psychological wellbeing. Psychotherapy aimed at gender change failed to be effective and even increased disstress and thus is widely considered unethical. ž žDiagnostic process includes 4 – 6 months and includes several visists with the sexologist. Then a Real Life Test follows as a part of this process. ž žSocial transition is a change of the gender role in society, includes coming-out and changes (name, addressing) ž žSpecialist assessments are necessary only in particular cases when in doubt – genetics, psychiatry, neurology žIf the gender dysphoria is severe and social transition does not reduce it, other treatments can be offere: ž ›Fully reversible procedures (puberty blocking agents - GnRH analogues) ›Partially reversible procedures (cross-sex hormones) ›Irreversible procedures (surgery) ›