Icm - Sex Summaries

Cross-cultural issues in sexuality More sex on prime-time TV than other times (most sex on soap operas, movies, talk shows…) Inis Baeg in Ireland – sex is totally taboo. Mangaians in South Pacific – lots of teen sex, not taboo People are not having a lot more sex now than before Single 20 year olds do not have more sex than married 30 year olds Single women over 40 have the least sex of all Americans Most Americans are overwhelmingly satisfied with their sex lives 83% of our sex partners are within 5 years of our age 90% are same race/ethnicity 68% are same religion (93% same/similar religion) <2% of men with college degree choose women who have no high school diploma; but only 8% choose women with a graduate degree 59% of population has 0-4 sexual partners in lifetime The greater the education, the greater the number of partners 80% women, 65-85% men remain faithful during marriage Only vaginal intercourse has nearly universal appeal In US, about ¾ of couples engage in oral sex, about ¼ engage in anal sex 4-7 times per month is average; 15-60 minutes each time Age of first sexual activity seems to be inversely related to legal age of consent in many countries US has highest teenage pregnancy rate of developed countries (& one of highest abortion rates) 60% marriages globally are arranged 50% US married couples are adulterous; 49% get divorced Age at first marriage in US – 26.9 (men), 25.3 (women); age at first divorce – 30.5 (men), 29 (women) People are sexually active well into 80s, 90s (i.e., 80% of 70-year-olds, 50-60% 80-year-olds) 1

Similarities across countries – established minimum age of sexual consent; adult porn regulated by gov’t; child porn not tolerated; incest is taboo

Female sexual response, part 1 Prevalence of sexual problems 48% couples have difficulty getting excited, 46% have trouble reaching orgasm, 15% unable to have orgasm, 14% say sexual relationship is not satisfying 60-80% people rate sex as important in their lives, their relationships Female sexual response cycle 1) excitement 2) plateau 3) orgasm 4) resolution intimacy-based model of sexual response 60% of women never initiate sex some women have a rather linear passage through these stages; others reach plateau and stay there (never orgasm); others reach plateau and then have multiple orgasms (Masters and Johnson, 1966) Responses to sexual stimulation CV/pulm: HR elevated by late plateau phase, possibly up to 180 bpm. Increased rate reflects increased orgasmic intensity; higher rates seen during masturbation than partner sex (not true for men – new/forbidden partner produces highest HR) RR – tachypnea may not develop until late plateau phase, possibly up to 40/min. Clinically observable tachypnea may not occur with low intensity orgasm BP elevated in late plateau phase by 30-80 mmHg (systolic), 20-40 mmHg (diastolic) breasts: plateau phase – areolae become markedly engorged, size increases up to 25% (less in women who have previously nursed) orgasm phase – no specific breast response to orgasm; vasocongestive responses are at peak resolution phase – flush disappears, areolae lose tumescence, “false” nipple erection (because breast contracts); vasocongestion lost slowly, over 10 minutes skin: “sexual flush” – seen in ¾ of women; can act as indicator of sexual intensity; primarily due to vasocongestion; mottled skin, sensation of warmth; usually over epigastrium, breasts, chest urethra, bladder: involuntary distention of urethral meatus during orgasm postcoital dysuria (should get up & pee after sex to flush out bacterial that can get from perineum to bladder with ‘thrusting’ – avoid ‘honeymoon cystitis’) rectum: voluntary contraction of external rectal sphincter, gluteal muscles during excitement, plateau (autoerotic – pumps even more blood into genitals) involuntary rectal sphincter contraction during orgasm (to avoid BM!) MSK: plateau phase – myotonia (generalized & specific), clutching reflex, carpopedal spasm (feet down, toes point up), rectus abdominus & gluteus contract; may help maintain vasocongestion brain: frontal lobes – variable involvement 2

occipital, parietal lobes – minimal involvement temporal lobes – involved in emotional responses (limbic system) cerebellum – considerable movement hypothalamus – hormonal mediation (women most receptive to sex in pre-ovulatory phase & premenstrual phase) Nulliparous women: labia majora – thin out, flatten against perineum; elevate, move upward/outward, away from introitus (may be secondary to changes in vagina or labia minora); may persist for several hours labia minora – by plateau, increased up to 3x normal diameter; may cause separation from labia majora; adds 1cm to length of ‘vaginal barrel;’ marked color change (red wine) always seen when orgasm is experienced (fades 10-15 min. later) – pathognomonic of impending orgasm Multiparous women: labia majora – labial viscosities are more prevalent; become distended, engorged; may increase 2-3 times in diameter (can be painful); slight lateral movement seen; labial vasocongestion may persist for 3 hours after orgasm labia minora – color changes more intense than in nulliparous women Bartholin glands: vestigial scent glands; produce small amount (1-3 drops) of mucoid secretion in late excitement/early plateau phase multiparas > nulliparas may serve as initial lubricant of introitus; more lube can be elicited secretions reduce vaginal acidity ( sperm longevity) clitoris: anatomy – consists of 2 corpora cavernosa enclosed in dense fibrous capsule; each corpus is connected to the rami of the pubis by a crus; suspensory ligament inserts into anterior surface; ischiocavernosus muscles insert into crura (originate from ischial rami) glans measures 4-5mm on average; clitoral shaft varies markedly in length (cm); size of clitoris is unrelated to sexual performance/enjoyment innervated by dorsal nerve (from pudendal nerve); dorsal nerve terminates in a nerve plexus in glans, corpora cavernosa; myelinated & unmyelinated fibers; autonomic nervous system blood supply from deep & dorsal clitoral arteries (branches of internal pudendal artery); similar vascular pattern to penis, with smaller volume vessels excitement phase – swells, becomes ‘erect’ (observable or not); much less rapid than penile swelling; swelling causes friction against clitoral hood plateau phase – retracts, turns upwards 180 degrees (hides!); crura, suspensory ligaments, ischiocavernosus muscles are responsible for this; completely withdraws under clitoral hood; 50% reduction in length; allows for friction from symphysis and hood orgasm phase – nothing happens to the clitoris! resolution phase – returns to normal ‘overhang’ position in 5-10 seconds after orgasm; detemuscence of glans is slower (30 min.); may remain engorged for several hours if no orgasm is reached vagina: responds to penile penetration; receptacle for ejaculate; responses to both somatic & psychogenic stimuli excitement phase – vaginal lubrication is first sign of sexual stimulation in women; begins 10-30 sec after stimulation is perceived; transudate from vaginal walls due to engorgement of venous plexuses; no glands; neural mediation via parasympathetic S2, 3, 4. Distensible potential space. Cervix & corpus elevate. Inner vaginal lumen expands (from 2-6cm); vaginal length increases (from 8-10cm); color changes (vasocongestion), rugae flatten. plateau phase – outer 1/3 becomes markedly distended; outer lumen diameter decreases (up to 50%); orgasmic platform develops; further lengthening occurs; production of secretion slows 3

orgasm phase – orgasmic platform contracts at 0.8 second intervals; max # contractions is 10-15 per orgasm resolution phase – lumen of outer 1/3 increases in diameter, returns to baseline; posterior/lateral walls of inner 2/3 retract, return to normal position in 3-4 minutes; coloration subsides in 10-15 minutes (longer if no orgasm) uterus: excitement phase – tenting begins (not in RF); broad ligaments become engorged; uterine size increases (up to 100% due to vasocongestion) plateau phase – full elevation is complete; vagina is maximally tented orgasm phase – myotonia is maximal at onset of orgasm; contractions occur, starting at fundus & progressing downwards; similar to early labor but less intense, more frequent; contractions begin 2-4 seconds after contraction of orgasmic platform begins, after awareness of orgasm occurs Orgasm a psychophysiologic response a myotonic response under sympathetic control associated with specific EEG patterns in each hemisphere no refractory period for women lots of variation among women The G-Spot named for Grafenberg (1950) located on anterior vaginal wall, midway between pubis & cervix, in region of bladder neck ranges in size; size unrelated to orgasmic experience prostate-like secretions

Female sexual response, part 2 98% of pts think it’s appropriate to ask questions about sexuality 53% pts have sexual concerns at time of medical visit take sexual hx to get complete hx, identify pt’s fears about exam, give permission to discuss subject, assess risks, understand impact of medical conditions on sexuality, dispel myths Kinsey – never invite a negative answer Goldman – never assume people know what a word means Orwell – never use a big word where a little one will do Mitford – save the hardest questions for last P-LI-SS-IT Model – permission (to discuss it now or in future), limited information, specific suggestion, intensive therapy (most of us will only do first three) Sexuality spiral – depression, obesity, diabetes, anorgasm Sexual Desire Disorders Sexual aversion disorder (SAD) persistent or recurrent phobic aversion to/avoidance of sexual contact with a sexual partner; causes personal distress Hypoactive sexual desire disorder (HSDD) persistent or recurrent absence of sexual desire which concerns your pt (be sure to ask: “Does this bother you?”) 11-48% of women have inhibited sexual desire – most common concern expressed by pts. Dissatisfaction with their relationship is the most common cause. 4

Sexual Arousal Disorder persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress may be expressed as lack of subjective excitement/lube/swelling, etc. contributing factors: meds (SSRIs, anti-HTNs, OCs), medical conditions, psychosocial, pain (after vaginal surgery/hysterectomy/radiation, episiotomy), other (lack of privacy, poor communication, pg., inadequate stimulation, knowledge deficit) medical conditions – neurologic (MS, peripheral neuropathies, stroke), weight (anorexia, obesity), endocrine (thyroid, diabetes, hyperprolactinemia, adrenal disorders), CV (HTN, CAD, MI), pelvic (dyspareunia, perineal sensation), other (bowel/bladder disease, renal disease) psychosocial – intrapersonal (guilt, etc.), historical (abuse hx, etc.), interpersonal, life stressors (biggest one – financial, family illness/death, depression) lab assessment – free T, thyroid panel, blood sugar level, LFTs, renal function, serum corticosteroids tx – counseling, education, referral to neurologist/endocrinologist, etc. Female Orgasmic Disorder persistent or recurrent difficulty, delay in, or absence of attaining orgasm after sufficient sexual stimulation & arousal, which causes personal distress is it primary or secondary? with coitus alone or with clitoral manipulation? tx – permission for sexual exploration, explain sexual response cycle, kegel exercises, sensate focus exercises, clitoral hood resection (rarely) medical tx methyltestosterone (cream) – problem is that people will refuse to stop using it, and it has bad AEs (bad lipid profile, clitoral megaly, hair growth, etc.) DHEA (dietary supplement) – acts as androgen/estrogen; don’t give if hx of hormone-dependent tumor sildenafil – helps women whose orgasm disorder is related to CV disease alprostadil, minoxidil (drugs designed for men) Eros-CTD – mechanical device; pump that increases vascularity of area (pump every day for several weeks, costs $300-400, need Rx) female Viagra alternatives – creams, gels, herbals, etc. Avlimil – has soy, licorice, black cohosh, bayberry, raspberry leaf… AE: hyperaldosteronism in post-menopausal women Sexual Pain Disorders Vaginismus – recurrent or persistent involuntary spasm of musculature of outer third of vagina that interferes with coitus (happens before penetration). Tx – counseling (always include partner), use of graduated dilators (pt’s fingers, tapered candles). Dyspareunia – difficult/painful intercourse primary: *superficial (congenital deviations, firm perineum, thick hymen, small introitus, vaginismus), *deep (congenital deviations, retroflexion/version of uterus, android pelvis, hx of pelvic fracture) secondary: *superficial – insufficient lube, infections, allergic responses to latex/spermicide, hypoestrogenic, meds (OCs, antihistamines), clustering of sexual activity *deep – infection (PID), uterine prolapse, pelvic adhesions/scar tissue, endometriosis, fracture of the coccyx, pelvic tumors Pregnancy first trimester nulliparous women – decreased libido, sexual response parous women – no change second trimester – arousal, sexual activity, sexual response increased in nulliparous & parous women 5

third trimester – frequency of coitus decreases as pg approaches term don’t have sex if vaginal bleeding, hx of pre-term labor, ruptured membranes postpartum – hypoestrogen, incision pain, body image, new role anxiety Cancer altered self image/sense of loss hormonal changes physical injury to genitalia shortened vagina/change in uterine position diminished clitoral sensation change in bowel/bladder function

pain with intercourse

Aging decreased hormone levels estrogen loss – vaginal dryness, breast softening, slower response/intensity of orgasm, decreased sensation, incontinence T loss – decreased libido, clitoral response, pubic hair physiologic changes body image chronic illness other changes of menopause skin – decreased tactile sensation breasts – decreased fat content, swelling, nipple erectile response vagina – shortening & loss of elasticity, decreased secretions, epithelial thinning (“pink, moist, irrigated” in young women; “pale, thin, smooth” in older women) internal reproductive organs – atresia & atrophy, cervic decreases mucous production bladder – urethra & bladder trigone atrophy

Male sexual response Male sexual response cycle libido (desire), erection (arousal), ejaculation/orgasm, satisfaction/resolution T11 – L2 parasympathetic pro-erectile (p for pointing) S2 – S4 sympathetic anti-erectile (s for shooting) S2 – S4 autonomic also involved Physio of penile erection contractility of penile smooth muscle governed by NTs, hormones, endothelium-derived substances (NE, PGE, endothelin Ca++ SMC contraction expression of receptors ion channel homeostasis signal transduction mechanisms interaction between contractile proteins SMC communication relaxation of penile smooth muscle (erection) cAMP, GC, cGMP, NO Ca++ SMC relaxation during an erection, the sinusoids & arteries relax blood rushes in CT doesn’t stretch much, so the veins get compressed, trapping blood in penis Erectile dysfunction 6

highly prevalent (1/2 of men aged 40-70 yrs), age-related, may be progressive associated with heart disease (especially if smoker), depression, diabetes, HTN, less education, unemployment, LUTS (lower urinary tract symptoms) causes vascular – either blood can’t get in or it can’t stay in (atherosclerosis, HTN, hypercholesterolemia, DM, trauma…) neurogenic – spinal cord disorders most common, also alcoholism/drug abuse, DM, MS, Parkinson’s, stroke, tumors, uremia… hormonal – primary hypogonadism, central hypogonadism (gonadotropin def, chronic illness, hyperprolactinemia), hypothyroidism, hyperthyroidism drug-induced – anti-HTN, ADs, antihistamines, anti-androgens, tobacco, alcohol, cocaine, heroin, meth, ecstasy anatomical/structural – congenital (curvature, micropenis), acquired (Peyronie’s disease, corporal fibrosis) psychogenic – generalized (lack of arousability), situational (partner-related, performance-related) dx – thorough H&P, labs – glc, lipids, serum chemistries, total T (fasting AM), PSA, CBC (& possibly prolactin, LH, TSH, liver enzymes, urinalysis) specialized dx tests genital sensation testing office pharmacotesting (induce erection in office, do Doppler) arteriography with pharmacologically stimulated erection (mostly for trauma – i.e., if injury to internal pudendal artery is suspected) nocturnal penile tumescence testing (men normally have erections on & off while they sleep, so if their nocturnal erections are normal, it’s something psychosocial) cavernosometry/cavernosography (inject dye, see if it leaks) tx T replacement (for pts with hypogonadism) – patches or po psychosexual therapy oral therapies *sildenafil (Viagra) – PDE5 inhibitor; major AEs are HA, flushing, nasal congestion, dyspepsia. Contraindicated with concurrent use of nitrates. Potentially hazardous in pts with active coronary ischemia, CHF w/ borderline low BP/low volume status, on complicated anti-HTN therapies. Efficacy is 70-80%. Especially useful in spinal cord injuries, post-prostatectomy. *oral -blockers vacuum/veno-occlusive device – uniformly produces an erection, 2 yr satisfaction is 55%. Disadvantages – cumbersome, ‘unnatural,’ penile pain, ejaculatory blockage, petechiae, numbness intraurethral therapy – Alprostadil – semisolid pellet inserted. AEs: penile pain, dizziness/hypotension, syncope intra-cavernosal injection (ICI) Papaverine – for men with vasculogenic ED ICI Trimix (Papaverine, Phentolamine, Alprostadil) – the big gun (combo) ICI therapy in general – effective regardless of etiology, 20-50% dropout within first year, requires training, refrigeration, lack of spontaneity penile prosthesis – reservoir holding sterile water – passes through pipes to cause erection (can turn on & off) highly effective (85-90% success rates), curative, requires surgery, irreversible, costly, potentially causes infection, erosion, mechanical failure penile vascular surgery – variable success, invasive, surgical complications nutraceuticals – poor data, not recommended

Sexual orientation and gender identity 7

definitions sex – XX or XY sexual expression – primary, secondary sex characteristics intersex – sexual expression is combo of male & female. examples: virilizing adrenal hyperplasia (adrenogenital syndrome), Turner’s (XO), Klinefelter’s (XXY), AIS (t-fem), hermaphroditism, pseudohermaphroditism, enzymatic defects in XY genotype. gender – way biological sex is perceived, expressed gender identity – knowing oneself as F or M (starts around 18 months, firmly established by age 3) gender role – behaviors that identify a person as M or F (masculine/feminine); established age 3-5 sexual identity – perception of one’s sex, gender identity, sexual orientation sexual orientation – person’s potential to respond with sexual excitement to people of same/opp sex transsexual – born one sex, gender identity is opposite transgender – wishes to cross-live part- or full-time. May want hormones/cosmetic procedures, but generally not interested in genital reassignment surgery. transvestite (cross-dresser) – heterosexual, cross-dresses on occasion to explore opposite gendered experiences (defined as paraphilia in DSM-IV) drag queen/king – F/M impersonator whose dress is intended for performance. Usually gay. Gender Identity Disorder (transsexualism), DSM-IV persistent cross-gender identification, belief that s/he was born the wrong sex not concurrent with a physical intersex condition 1 in 20,000 males, 1 in 50,000 females Harry Benjamin International Standards of Care – eligibility, readiness criteria for hormonal/surgical tx. hormonal therapy – eligibility: 18 or older, demonstrated knowledge of effects of hormones, ‘real-life’ experience x 3 mos. readiness: further consolidation of gender identity, stable mental health, likely to take hormones responsibly surgical therapy – eligibility: 18 or older, 12 mos. continuous hormonal therapy, 12 mos. continuous ‘real-life’ experience, regular psychotherapy, understanding of procedure. readiness: further consolidation of gender identity, progress in dealing with impact on work, family, interpersonal relationships. Gender non-conformity one of strongest predictors of sexual orientation boys who exhibit significant gender atypical behavior have 50% (to 75%) chance of becoming gay girls – 6% chance of becoming lesbian Sexual behavior Kinsey scale – 7-point hetero-homo scale Kinsey – 8% men, 4% women are exclusively homosexual; 37% men, 20% women report at least one homosexual experience resulting in orgasm recent studies – 12-25% of men have had homosexual contact in their lifetime; 5% men are actively gay 3-5% of women have had a homosexual experience since puberty; 2-3% are gay (women especially underreported – studies often only address intercourse, not sexual fantasies or other forms of intimate contact) APA removed homosexuality from DSM in 1973 – studies by Hooker, Ford, Beach showed lack of psychopathology in homosexuals The development of sexual orientation (theories) psychobiological sex hormone studies – thought gay men had too little T, gay women too much… not true. Prenatal exposure to high levels of testicular hormones might play a role. More research needed. 8

family/genetic studies – 4% straight men have brothers who are gay; 20% gay men have brothers who are gay (less pronounced in women) neuroanatomical studies – differences in cell groups in the anterior region of hypothalamus. Cluster of cells (oSDN) in hypothalamus of ‘gay’ sheep with higher levels of aromatase. Anterior commissure is larger in women, gay men than in straight men. Differences in cochlear sound emission for straight women compared to gay/bi women; may reflect differences in prenatal androgen exposure. psychosocial (decreasing in popularity) operant-conditioning theory – early sexual experiences are crucial to shaping one’s orientation psychoanalytic theories – men are gay b/c of strong mother, distant father exotic-becomes-erotic theory – ‘experience-based developmental’ theory – childhood gender nonconformity plays crucial role in future orientation sociobiological understand through evolutionary perspective (how can genes for homosexuality survive?) gene might be advantageous in heterozygous state gene might cause ‘hyper-heterosexuality’ in women – increasing reproductive success kin altruism – gay sibling might promote reproductive success of other siblings it’s likely there are several genes; complex interaction between biology & psychosocial mechanisms; multiple developmental pathways. Coming out avg age for awareness of same-sex attraction is 14 for men, 16-19 for women mean age of erotic arousal is 9.5 yrs for boys, usually spontaneous most people become to self-acknowledge gay identity in late teens, come out in early to mid-20s Stages of Coming Out (Cass 1996) prestage – still part of the majority Stage 1 – identity confusion Stage 2 – identity comparison (I may be gay and not straight) Stage 3 – identity tolerance (I am probably gay, but I’m not sure I like that about myself) Stage 4 – acceptance (I am gay) Stage 5 – identity pride (It’s us vs. the heterosexuals) Stage 6 – identity synthesis (I am more than just gay) Clinical issues ½ of gay men, 2/3 of lesbian women conceal their orientation from physicians 25% faculty at medical school admit they’re prejudiced against lesbian/gay lesbian health concerns – br ca, depression/anxiety, gyn ca, tobacco/substance abuse, alcohol, DV, heart health, HIV, STIs, relationships (starting a family) gay men’s health concerns – HIV/AIDS, substance use, depression/anxiety, hepatitis, STIs, prostate/testicular/colon ca, alcohol, tobacco, fitness, anal papilloma, relationships gay adolescent health concerns – suicide, HIV, STIs, substance abuse

Child maltreatment Categories of abuse include sexual, emotional, physical, and neglect. The latter two are the most common 44% of sexual assault victims are people under 18, 10% are male, <39% of sexual assaults are reported to police ¼ women are sexually abused/assaulted; 1/6 men Sexual abuse – any act involving sexual molestation or exploitation of a child by a parent or other person who has permanent or temporary care or custody or responsibility for supervision of a child, or by any household or family member. This is usually a care-giver, like a teacher or uncle. 9

Sexual assault – any type of sexual activity that is not wanted or agreed to. Might be from a stranger. Behavioral indicators of abuse Violent – portrayed in artwork, schoolwork, language, play; violence against other kids; fire-setting Aberrent acting-out behavior overly-compliant behavior pseudo-mature behavior repulsion/extreme fear when touched by an adult excessive bathing fear of being alone fear of bathrooms/showers sleeping problems encopresis – involuntary passage of stool. enuresis – wetting oneself. depression self-mutilation dissociative disorders substance abuse poor peer relationships difficulty concentrating, poor academic performance avoidance of “fun” things running away eating disorders delinquency developmental delay chronic illness (pain, headaches…) Sexual excessive masturbation (that can’t be redirected) hinting about sexual activity; promiscuity (adolescents often manifest these behaviors) Parental behaviors of concern inappropriate expectations of child (especially with physical abuse, neglect) psychiatric impairment substance abuse domestic violence kids are not well-supervised, left in care of someone else Preschool age children failure to thrive, excessive clinging behavior or overly-compliant challenges – verbal skills, may have imaginary friends (credibility questioned), custody disputes School age children sleep disturbances, changes in appetite, decrease in school performance challenges – are they lying?, custody disputes Adolescents truancy, anti-social behavior, depression, substance abuse challenges – questions of consent, sexually active, other at risk behaviors, is the person lying? Age of consent 10

16 in DC, MD; 18 in VA if age difference is >4 years and person is below age of consent statutory rape “rape shield law” – can’t talk about victim’s sexual history in court Importance of history studies have been done after disclosure of sexual abuse – examine anogenital area. The vast majority of exams are normal. semen may be found in adult women up to 72-96 hours after sex, but in children, it’s only about 24 hours hymen can be annular, crescentic in a newborn, maternal estrogen hymen is redundant, pale, less sensitive to pain, more elastic in pre-pubescent, the hymen is pinker (less estrogen) in adolescent, there’s estrogen again, so hymen is again redundant, elastic, pink The Anogenital exam frog-leg position, knee-chest position, lithotomy don’t usually use a speculum for a sex abuse exam when the person is anxious, the hymen might not be as open – hard to see edges. in an adolescent, since they have increased estrogen so the hymen isn’t too sensitive, you can insert a little balloon and inflate it to better see the edges of the hymen Findings diagnostic of trauma and/or sexual contact acute lacerations or extensive bruising of labia, penis, scrotum, perianal tissues, perineum, hymen, posterior fourchette healed hymenal transaction in posterior rim missing segment of hymenal tissue in posterior rim scar of posterior fourchette, fossa navicularis or perianal scar positive gonorrhea culture, HIV/syphilis trichomonas vaginalis in child >1 yr. positive chlamydia culture in child >3 yrs. sperm in specimens taken from child’s body ddx – Lichen sclerosis (atrophic skin disorder), Behcet’s Disease (ulcerative disorder), Group A Strep, urethral prolapse, Crohn’s Disease, neurogenic patulous anus (‘gaping anus’), linea vestibularis (hypopigmented line in perineum – normal), failure of midline fusion, diastasis ani (groove in anus), anal verge anatomy (looks bruised). exam findings alone don’t make dx. history, child’s disclosure are crucial. Safer sex, HIV testing, HIV prevention counseling ‘discordant’ – describes relationship in which one partner has HIV and the other doesn’t HIV antibody tests: ELISA – greater sensitivity, worse specificity than Western blot (can also do PCR for viral load) harm reduction – if person is unwilling to practice 100% safe sex, compromise (i.e., don’t ejaculate in mouth, don’t brush teeth before oral sex, etc.) if rapid HIV test is negative, the person either doesn’t have HIV or they haven’t seroconverted yet (3 mos). If positive, it’s a preliminary positive – need to send for additional testing. 24-27% of HIV+ people in US are unaware of it. 40,000 new inf/yr. fluids that can transmit HIV: blood, semen, pre-cum, vaginal secretions, breastmilk fluids that have HIV but in low quantities: saliva, tears, sweat, urine, feces, vomit don’t use oil-based lube with condoms (Vaseline, Crisco, hand lotion, baby oil) female condom is made from polyurethane don’t use male condoms with female condoms nonoxinol-9 – spermicide, but lots of allergic reactions, increased risk for HIV 11

Pubertal development puberty – physical changes of body that occur in going from child to adult; culminates in ability to reproduce adolescence – psychosocial maturation from the child to the adult Female puberty begins age 8-13, usually completed in 4 yrs breast buds appear first (thelarche) – Tanner staging pubic hair appears (adrenarche) growth spurt (occurs earlier in puberty for girls than boys) axillary hair pubic hair matures, breasts mature, menarche, full adult height menarche – average 12-13 yrs (ranges 10-16); occurs late in puberty; growth rate slowing down (98% of adult height at menarche); bldg is often irregular in beginning Tanner staging for female breast development Stage 1 – No Breasts Stage 2 – Slight breast development Stage 3 – More development Stage 4 – “2 Scoops” – a development of breast mound with some more breast tissue Stage 5 – Normal female breast Tanner staging for female pubic hair Stage 1 – No Pubic Hair Stage 2 – A Little bit of pubic hair; very scant Stage 3 – A little bit more hair but still straight Stage 4 – Pubic hair is curly – straight vs. curly is the distinguishing factor between stage 3 and stage 4 Stage 5 – Pubic hair extends down towards the thigh and up towards the abdomen Male puberty begins 9.5-13.5 yrs, usually completed in 3 yrs testicular enlargement starts the process pubic hair appears (adrenarche) growth of penis & scrotum spermarche axillary hair growth spurt facial hair maximum strength spurt adult height Tanner staging for male genital/pubic hair Stage 1 – child version of penis, testicles and pubic hair. Stage 2 – testicular enlargement and a little bit of pubic hair. Stage 3 – more pubic hair but it is straight Stage 4 – Pubic hair curls (growth spurt usually around here) Stage 5 - progressive enlargement of the penis, scrotum and testicles Changes in organ systems heart – grows 20% in adolescence; more sensitive to postural changes eyes – myopia may occur during puberty 12

skin – acne: incidence approaches 80-90%; increased sebum production stimulated by androgens MSK – scoliosis (lateral curvature of spine), Osgood-Schlatter Disease (stress changes in tibial tuberosity at site of attachment of patellar tendon; occurs during pubertal growth spurt) Three psychosocial developmental stages early adolescence (11-14) concerns about physical changes; narcissistic, wide mood swings, invulnerable, poor impulse control independence starting; non-parent role model ‘crushes’; intense same sex friendships; complex concrete cognitive abilities middle adolescence (15-17) pubertal physical changes completed – showing off/testing ‘new’ body parental conflicts at peak, strong peer group identity sexual attraction/activity, peak risk-taking behaviors, more idealism/fatalism, abstract cognitive dev late adolescence (18-21+) independent adult roles, responsibilities, reacceptance of family values/role can achieve true intimacy, peer group less important, realistic self-identity ability to compromise & set limits, understand vulnerabilities, have moral/ethical/sexual codes Adolescent developmental tasks establishing independence from parents/family adopting peer codes/lifestyles establishing intimacy accepting body image establishing sexual, vocational, moral identities Effects of pubertal timing early maturing females – vulnerable to more risk-taking behaviors, more problems with adaptation, unwanted sexual attention from older males, being drawn into older peer groups ‘on-time’ maturing females – have better body image than early or late maturers early maturing males – given more leadership roles, better at sports, perceived as popular, smart, etc. later maturing males – more personal, social maladjustment over entire adolescence; insecure, suggestible Leading causes of death in adolescents injuries – MVA (#1), especially at night or with teen passengers; brain immature until age 25 homicide – usually by friend/acquaintance, often related to drugs/alcohol, usually handgun suicide – attempts outnumber successes 200 to 1; F>M attempts; M>F by 4x for successful suicides Gynecomastia peak prevalence (64%) at age 14; mean age of onset is 13 imbalance between circulating estrogens & androgens or from altered sensitivity of breast tissue receptors to change in ratio of estrogens & androgens (growth of glandular tissue – not overweight) usually resolves in 12-18 mos; mastectomy can be considered when mass persists beyond puberty (>4cm) Confidentiality adolescents can get confidential care for STIs, contraception, pg, substance use, psychological distress emancipated minors – 16 or older; allowed to receive any health care without parental consent. Marriage, self-supporting & living on own, military service, parenthood (in MD, VA, but not in DC)

Contraception and abortion 13

Contraceptive use sterilization is the #1 method used in the US and worldwide the Pill (OCs) is #2 for the US all the other methods combined don’t equal the prevalence of the Pill male methods account for a large proportion of contraceptive use new method of female sterilization – “non-surgical tubal occlusion – Essure.” office procedure, 5 minutes. By inserting a microcoil in the fallopian tube, scar tissue occludes the tube. OCs can be tri-, bi-, or monophasic, combined or progestin-only (progestin-only just thickens cervical mucous) Absolute contraindications for hormonal methods Pregnancy/lactation Liver tumor Estrogen dependent tumor Prior hx of DVT Smoker > 35 yrs. old Undiagnosed vaginal/uterine bleeding Relative contraindications for hormonal methods Hypertension Migraines –if women have sequelae like slurred speech, difficulty moving their limbs, etc. Mechanisms of action for hormonal contraception Inhibits ovulation by suppressing FSH, LH Thickens cervical mucous Slows transport of ovum Thins endometrial lining Advantages to hormonal methods Menstrual benefits (periods lighter, shorter, more predictable) Decreased risk of ovarian & endometrial cancers (if on OCs for >5 yrs) Decreased risk for benign breast disease Improvement in acne Decreased hirsutism Improvement of other medical conditions (like endometriosis) Disadvantages to hormonal methods Daily administration, expense Side effects –HA, nausea, BTB, breast tenderness, decreased libido, vaginal dryness, depression. Increased risk of chlamydia Hypercoagulability Acceleration of gallbladder disease (GBD) Advantages of injections (DMPA, Lunelle) Extremely effective, low user dependence Decreased seizures, PMS, breast tenderness, risk of PID Most women have amenorrhea Disadvantages of injections Long wait for fertility to return Have to get an injection regularly 14

Side effects weight gain – average 5-20lbs in first 3 years of use decreased HDLs decreased bone density –don’t use Depo > 5 yrs irregular bleeding skin problems Intrauterine devices (IUDs) Copper T (Paraguard) – works for 10 years; causes ‘foreign body response’ in uterus ( inflammatory response). Copper allergies are rare. Mirena – works for 5 years, releases progestin. Less cramping & bleeding than with Copper T Advantages Effective long term usage Immediately reversible Not user dependent Disadvantages Expulsion in first 3 months Increased risk for infertility Increased risk of PID Increased dysmenorrhea, menorrhagia Mechanism – thickening cervical mucous, inhibiting sperm motility, thinning endometrium, and inflammation (foreign body response) Condoms Cervical caps & diaphragms work best with nulliparous women Advantages Low cost per use Uninterrupted foreplay (can put in a couple hours before sex) Non-hormonal Decreased STI risk Disadvantages Must be fitted User dependent Allergy Increased risk of UTI Possibility of TSS? Prentif cervical cap, FemCap Non-latex cervical caps – Lea’s Shield Non-latex cupped volume bowl, held in place by thick posterior lip Put spermicide inside Made of silicon, not latex Spermicides Advantages – cheap, accessible, non-hormonal, inhibit STI growth in vitro Disadvantages – high failure rate, reapplication required, increased UTI/yeast inf, allergy, vag irritation Natural family planning Lactational Amenorrhea Method (LAM) – must breastfeed every 2 hrs 15

Rhythm Method –take basal body temperature, look for nadir (lowest point is about 24 hours before you ovulate). Temperature spikes at ovulation, remains high for rest of cycle Emergency contraception high dose OCs/Preven – take antiemetic beforehand; 2 doses, 12 hrs apart Plan B – progestin-only Possible mechanism of action for EC Inhibits ovulation Inhibits tubal transport of egg/sperm Interferes with fertilization, early cell division, or transport of embryo Prevents implantation by disrupting uterine lining Progestin-only EC may immobilize sperm by altering uterine pH Progestin-only EC can alter glycodelin in serum & endometrium shorten luteal phase if she’s already pregnant, progestin won’t hurt baby. no documented cases of birth defects from OCs! Future contraceptive options Nestorone (transdermal spray), chewables, single rod implant, MENT (synthetic androgen for men) Carraguard – microbicide, derived from seaweed, blocks infection by HIV, HSV2, HPV, N. gonorrhea Abortion

Sexual behaviors teen sex is declining (recent trend); birth rate among teens has fallen since 1991 by age 15, 1/3 of males, ¼ of females have had sex; by age 19, 80% males, 70% females have had sex more young adults are unmarried and sexually active now than before adults >25 – marriage/cohabitation. multiple partners more likely in unmarried, men, <30, blacks. women – abstinence, monogamy is more common. 10-25% population has hetero anal sex increasing age, declining health of partner are independent predictors of decreased frequency of sex in elderly ½ of men, 1/3 of women masturbate into their 90s love & intimacy – “active receiving” – a person, while loving, permits him/herself to be loved.

Medical illness and sexuality heart disease increased physical demands, fear of overexertion high risk of ED among men with HTN (HTN’s effect on women unknown) illicit sex is not safe; only 1% of MIs are associated with sex; regular exercise makes sex safer atherosclerosis decreased intracavernosal pressure, Q, ischemia of trabecular smooth muscle fibrosis failure of venous closure mechanism diabetes impotence, decreased libido peripheral neuropathy may impede women’s lubrication, ability to achieve orgasm men get ED HTN impotence, drug effects atherosclerosis impotence stroke decreased libido, less frequent orgasm cancer breast cancer – disfigurement, fear of loss of physical attractiveness prostate cancer – impotence, incontinence fear of death, infertility 16

ostomies (colostomies, urostomies) gyn cancers – hysterectomy may lead to vaginal scarring, dyspareunia MS decreased physical capacity, difficulty with orgasm, incontinence arthritis physical pain, joint stiffness, limited ROM, decreased ability to masturbate avoid weight-bearing positions, use pillows & lube Sjogren’s syndrome decreased secretions, including vaginal SC injuries impotence, decreased ability to achieve orgasm depression decreased libido, anhedonia (anti-depressants, too) HIV skin disorders urinary incontinence drugs – OCs (decreased libido & lube), tamoxifen (atrophy, decreased lube) hysterectomy – vaginal scarring, dyspareunia menopause – vaginal atrophy, dyspareunia Dyspareunia due to hormone deficiency tx with vaginal lubricants, HRT, topical estrogens, testosterone Sexual dysfunction and paraphilias Sexual reproduction requires gonadal, genital, behavioral differentiation. Disorders of desire hypoactive sexual desire disorder absent/deficient sexual fantasies/desire for sexual activity, causing marked distress if global/lifelong, evaluate hormonal levels. if situational therapy 33% prevalence for women, 15% for men sexual aversion disorder extreme aversion to/avoidance of genital sexual contact, causing marked distress tx = therapy, anti-depressants Disorders of sexual excitement Female sexual arousal disorder inability to attain/maintain until completion adequate lubrication-swelling response affects 10-15% of women can be from pain disorders, meds, post-menopausal, anxiety/guilt/fear, ‘spectator role’ tx – look at fantasies, encourage experimentation, sensate focus therapy Male erectile disorder inability to attain/maintain until completion adequate erection differentiate as much as possible by hx – masturbation, morning erections, with all partners… lifelong prevalence is 1%; 25% by age 75 tx – spontaneous, hypnotherapy, medication, mechanical, sensate focus therapy Disorders of orgasm Female orgasmic disorder delay in/absence of orgasm – less than would be reasonable for age, sexual experience, stimulation prevalence = 30%; 77% women are anorgasmic with coitus, only 4% with masturbation normal-average arousal-to-orgasm time is 8 minutes Male orgasmic disorder delay in/absence of orgasm prevalence = 4-10%; rarely lifelong; usually generalized 17

person may be controlling, unemotional, untrusting, hostile… Premature ejaculation ejaculation with minimal sexual stimulation, not due to direct effects of a substance (opioid with.) more prevalent in college-educated men; 30% male population, 40% men treated for sexual disorder tx = SSRIs, topical anesthetics, squeeze technique Sexual relaxation disorders – not part of DSM, but can be related to tx of sexual disorders priapism – prolonged, painful erection; always medical (not psychogenic) Sexual pain disorders dyspareunia genital pain in M or F associated with sexual intercourse 30% of all surgeries on female genitalia temporary dyspareunia vaginismus involuntary spasm of musculature of outer third of vagina less frequent than anorgasmia; more common among highly educated, higher socioeconomic status fear of penis; strict religious upbringing; prior sexual or painful nonsexual trauma Sensate Focus Therapy Masters & Johnson – eliminate ‘spectator role’ 4 stages Stage 1 – focus on sensation of touching/being touched (silence encouraged) Stage 2 – genital touching okay but not the focus; ‘hand-riding’ (one person guides the other’s hand) Stage 3 – mutual touching Stage 4 – intercourse Paraphilias exhibitionism, fetishism, frotteurism, pedophilia, S&M, transvestic fetishism, voyeurism, etc… Sexual addiction – not a DSM dx.

18