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The Human Sexual Response

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1 The Human Sexual Response
Amr Nadim, MD Professor of Obstetrics& Gynecology Ain shams Faculty of Medicine & The Women’s Hospital

2 LEARNING OBJECTIVES By the end of this lecture, you should be able to:
Describe normal sexual response. List common sexual problems and their definition. List causes and management of frigidity, dyspareunia, and vaginismus.

3 Human Sexual Response Masters and Johnson: four phases
• Excitement/arousal • Plateau • Orgasm • Resolution

4 The sexual response cycle in humans progresses through four phases:
Excitement Plateau Orgasm (climax) Resolution

5

6 Excitation: Vasocongestion: pelvic area receives more blood in general, in particular to genitals. Males: penile erection scrotal sac thickens, elevates Females: vaginal lubrication glans clitoris enlarges (similar to penile erection) nipples erect (myotonia: muscle contraction) breasts enlarge (vasocongestion inner lips of vulva swell and open, change in colour (darker) upper 2/3rds of vagina balloons cervix and uterus stand up: tenting effect angle of cervical opening more receptive to sperm Both Sexes: sex flush (can happen later) heart rate, respiration rate gradually increase generalized myotonia

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8 Plateau: Both males and females continue vasocongestion to max
Heart rate, respiration rate and blood pressure continue to increase Copious perspiration Increased myotonia

9 Plateau (Cont’d) Females:
orgasmic platform: outer third of vagina thickens, swells: condition sine qua non: without it, no orgasm tenting complete clitoris erect

10 Plateau (Cont’d) Males:
Cowper’s glands secrete fluid through tip of penis. WARNING: may contain live sperm! scrotum even higher and testicles bigger

11 Orgasm: Males: Two stages:
contraction of seminal vesicles, vas and prostate contraction of urethra and penis: ejaculation

12 Orgasm: Females: contractions of orgasmic platform
contractions of uterus several orgasms possible if stimulation continues oxytocin

13 Orgasm: Both: very high heart rate, blood pressure and breathing
intense myotonia

14 Health Benefits Associated With Orgasm
General Health An orgasm at least once or twice per week appears to strength the immune system’s ability to resist flu and other viruses Pain Relief Some women find that an orgasm’s release of hormones and muscle contractions help relieve the pain of menstrual cramps and raise pain tolerance in general. Better Sleep The neurotransmitter dopamine, released during orgasm, triggers a stress-reducing, sleep-inducing response that may last up to two hours

15 Greater Feelings of Intimacy
Lower Cancer Rate Men who have more than five ejaculations per week during their 20s have a significantly lower rate of prostate cancer later in life Mood Enhancement Orgasms increase estrogen and endorphins, which tend to improve mood and ward off depression in women Greater Feelings of Intimacy The hormone oxytocin, which may play a role in feelings of love and intimacy, increases fivefold at orgasm

16 Emotional Changes During Orgasm
Based on EEG, MRI and PET scans done in the lab while subjects having an orgasm. General emotional response: coded in limbic association area, especially prefrontal cortex and cingulate gyrus. Pleasure: coded in basal forebrain, especially ventral tegmental area and its dopaminergic stimulation of the reward centres of the septal nuclei and the nucleus accumbens. Euphoria: probably by assymetric cortical activation The proportion and intensity of each varies with each orgasm.

17 EACH PHASE MUST BE FULLY COMPLETED IN ORDER TO REACH THE NEXT ONE
Resolution Return to normal, muscles relax, breathing etc. back to normal, blood back to circulation from genitals. Males refractory period EACH PHASE MUST BE FULLY COMPLETED IN ORDER TO REACH THE NEXT ONE

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19 SOME GENDER DIFFERENCES
Excitation: women slower: cultural expectations, socialization pregnancy It is very important for male partner to make sure she is ready for plateau stage

20 Plateau: Orgasm: Resolution:
without orgasmic platform women can’t have orgasm. Orgasm: multiples for many women. Some women cannot go through resolution without several orgasms, vasocongestion persists. Resolution: women have no refractory period

21 “Pleasure centers”: (for arousal and orgasm)
Both: genital area Women (and some men): nipples, breasts, G-spot Men: prostate Many body areas can be: ears, back of knees, neck, feet, abdomen, thighs, inside of elbows, scalp

22 Retrograde Ejaculation:
Two separate valves or sphincters, one to let urine into urethra, and another to let semen into urethra. When one is open, the other closes. In some cases, the semen valve is closed and the urinary valve that opens to the bladder is open. Semen flows into bladder. No ill effects.

23 Resolution: Men: Women:
longer refractory periods, 24 hrs. midlife, longer in old age. Women: no refractory periods ever.

24 Each phase shows age changes
Excitation: Men: fastest years, then show decline Middle Age: very noticeable, need direct stimulation Old Age: need lots of direct stimulation Women: slower in teens, early 20s faster 30’s on Plateau: capacity for longer with age same, but never a big problem

25 Orgasmic: Resolution: Men: Middle Age: Refractory period increases
intensity lessens from mid- to late 20s Middle Age: really noticeable ejaculate less volume, less forceful Resolution: Refractory period increases

26 Females Intensity of Response Males Age

27

28 PHYSIOLOGY OF THE SEXUAL RESPONSE
Cognitive models: Kaplan’s triphasic model: sexual desire vasocongestion muscular contraction Walen and Roth’s model: emphasis on perception and evaluation, 8 steps, necessary for the arousal cycle to be completed

29 PHYSIOLOGY OF THE SEXUAL RESPONSE
Neural and hormonal involvement in sexual responses: Parasympathetic: arousal Sympathetic: orgasm Spinal reflexes: erection and ejaculation Erection: sacral cord responds to stimulation, sends message via parasympathetic to relax penile arteries: more blood flows to penis. Also, message to brain, awareness (not if spine severed above sacrum) Ejaculation: higher in spinal cord, message to sympathetic that causes muscle contractions. Also, message to brain, awareness, possibility of control

30 Women’s Neural Mechanisms:
Not yet well known Controversy surrounding G-spot and female ejaculation. One recent study found that sexual sensations can be transmitted to the brain via the vagus nerve, which is normally used for digestive processes.

31 PHYSIOLOGY OF THE SEXUAL RESPONSE
Higher Centres: limbic system: septal region of the amygdala

32 PHYSIOLOGY OF THE SEXUAL RESPONSE
Experiments using electrical stimulation: Erection centers found in the limbic system, both in monkeys and humans.

33 Hormonal Influences on Sex
Most Studied Sex Hormone: Testosterone produced by testes, ovaries and adrenal glands important for sexual desire in both sexes

34 Hormonal Influences on Sex
Women have 1/10th the amount but are ten times more sensitive to it. More testosterone in a normal person will not increase desire or response. Most testosterone is ‘bound’, not available in this regard, ‘free’ testosterone is 2-5%. Oxytocin, produced by the pituitary, important for female orgasm.

35 Chemistry of Attraction
DHEA (dehydroepiandrosterone): secreted by adrenal glands, weak androgen. Most sex hormones and pheromones derived from it. Same amount for males and females in bloodstream. Pheromones: sexual signals for both sexes. Oxytocin: released by the pituitary when touching or being touched by loved ones.

36 Chemistry of Attraction
PEA (phenylethylamine): called “the molecule of love”, produce euphoria, amphetamine-like substance produced in brain capillaries and in catecholaminergic terminals. Low PEA levels associated with depression (some depressions successfully treated with PEA). Some people become addicted to the PEA “high” and change partners frequently to get it, it is more abundant early in a relationship.

37 Chemistry of Attraction
Estrogen: makes women sexually attractive and receptive. Skin, lips, hair, fatty padding (curves), breasts, hips. Testosterone: increases sex drive in both sexes, too much is counterproductive. Endorphins: produced in the brain, released in response to touch and sex, produce positive feelings. Progesterone: testosterone antagonist, lowers sex drive (in the pill as well), mild sedative, calming effect.

38 Chemistry of Attraction
Serotonin: neurotransmitter. At low levels intensifies sex drive, at high levels decreases it. Antidepressants elevate serotonin, decrease sex drive. Dopamine: neurotransmitter associated with all pleasures, increases sex drive, promotes action. Prolactin: decreases sex drive, especially in men.

39 Chemistry of Attraction
Vasopressin: hormone produced by the pituitary, antidiuretic (water retention), increases blood volume and blood pressure, identified as the “monogamy molecule”, modulates testosterone, levels extremes of feelings, increases focus in lovemaking. All these substances fluctuate in a 24 hr. cycle, also with age and environmental events. The “high” of early love is short-lived (6-30 months). Cultural belief in passionate love forever not realistic.

40 PHYSIOLOGY OF THE SEXUAL RESPONSE
Hormonal Influences on Sex (Cont’d): Hormones are NOT directly responsible for human sexual behaviour, as they are in most animals. Psycho-social context and culture are the most important determinants. In real life, people in good relationships say that sex is better than in casual situations.

41 PHYSIOLOGY OF THE SEXUAL RESPONSE
Anatomy and physiology of sex only give us an idea of how our biological equipment tends to work, but it does not give us an understanding of human sexual behaviour. Knowing car mechanics does not make you a good driver! In order to get this, we need to explore our psychology, our communication styles, our culture/s, our interpersonal skills, etc.

42 Types of Sexual Dysfunction
Commonly the cause of sexual dysfunction is multifactorial and result in more than one dysfunction. Primary sexual dysfunction: Those who never had normal sexual activity. Secondary sexual dysfunction: Those who developed sexual dysfunction after a period of normal sexual activity.

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44 Prevalence of Sexual Complaints in Women
43% of women experienced a sexual problem 32% 28% 27% Percentage of Women* 21% Speaker’s notes: Community studies indicate that the prevalence of female sexual dysfunction ranges from 25% to 63%. This population study, a substudy of the National Health and Social Life Survey, was conducted in It is a probability sample among 1749 women and 1410 men, aged 18 to 59 years, in the United States, and is based on face-to-face interviews conducted by trained interviewers. The population is similar to the US Census Bureau Current Population Survey, representative for age, education level, and marital status. Following are the ranges of dysfunctions across the age groups: Lack of interest in sex: ~27-32% Unable to achieve orgasm: ~22-28% Pain during sex: ~8-21% Sex not pleasurable: 17-27% Using latent class analysis to group symptoms in categories, the study found that sexual dysfunction is more prevalent in women than men (43% vs 31%). Lack of interest was the most frequently reported female sexual complaint. References: Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281: *Women aged years Laumann EO, et al. JAMA. 1999;281:

45 Comorbidity of Anxiety and Depression With Sexual Problems
Increased association between anxiety or depression with sexual problems Odds Ratio* Speaker’s notes: These data are from a questionnaire sent to 4000 men and women registered with 4 general practices in England. Questions were regarding demographics, social problems (Social Problems Questionnaire), health history, and psychological status (Hospital Anxiety and Depression Scale). The response rate to the survey was 44% (women n=979, men n=789). A total of 41% of women reported a current sexual problem. The female sexual problems examined in this study were associated with anxiety and depression. Reference: 1. Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health. 1999;53: *Odds ratio for association between anxiety and depression and sexual problems Dunn KM, et al. J Epidemiol Community Health. 1999;53:

46 Comorbidity of Marital Difficulties and Sexual Problems
Increased association of marital problems with arousal, orgasm, or enjoyment problems Odds Ratio* Speaker’s notes: These data are from a questionnaire sent to 4000 men and women registered with 4 general practices in England. Questions were regarding demographics, social problems (Social Problems Questionnaire), health history, and psychological status (Hospital Anxiety and Depression Scale). The response rate to the survey was 44% (women n=979, men n=789). A total of 41% of women reported a current sexual problem. Arousal problems, orgasm problems, and inhibited enjoyment were associated with marital difficulties in the women participating in this study. Keywords: Sexual dysfunction Reference: 1. Dunn KM, Croft PR, Hackett GI. Association of sexual problems with social, psychological, and physical problems in men and women: a cross sectional population survey. J Epidemiol Community Health. 1999;53: *Odds ratio for association between marital difficulty and sexual problems Dunn KM, et al. J Epidemiol Community Health. 1999;53:

47 Female Sexual Dysfunctions
Desire Lack of sexual desire Desire discrepancy with partner Aversion to sexual activity Arousal Difficulties with physical and/or subjective sexual arousal Difficulties lubricating Difficulties sustaining arousal Orgasm Difficulties experiencing orgasm Pain Pain with sexual activity Difficulties with vaginal penetration (anxiety, muscle tension) Lack of sexual satisfaction and pleasure

48 Categories of Female Sexual Dysfunction
desire disorders Hypoactive sexual desire disorder Sexual aversion disorder Sexual arousal disorder Female sexual arousal disorder Sexual orgasmic disorder Female sexual orgasm disorder Speaker’s notes: This slide shows the categories of female sexual dysfunction based on the diagnostic and classification system of the International Consensus Development Conference on Female Sexual Dysfunction convened by American Foundation for Urological Disease. In general, the female sexual dysfunctions are categorized based on disruption of the female sexual response cycle. The definitions for the these categories encompass both biological and psychological factors, and most of these diagnostic categories include a personal distress criterion. Furthermore, more than one dysfunction may be present, and there may be interdependence among the disorders. This classification system has been criticized since it is based on the traditional linear model of female sexual response. In fact, subsequent publications have recommended changes, suggesting that the categories and their definitions will continue to evolve. Reference: 1. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163: Dyspareunia Vaginismus Noncoital sexual pain disorder Sexual pain disorders Basson R, et al. J Urol. 2000;163:

49 Female Sexual Dysfunction
Physiological Neurological problems Cardiovascular disease Cancer Urogenital disorders Medications Fatigue Hormonal loss or abnormality Psychological Depression/anxiety Prior sexual or physical abuse Stress Alcohol/substance abuse Female Sexual Dysfunction Interpersonal relationships Partner performance and technique Lack of partner Relationship quality and conflict Lack of privacy Sociocultural influences Inadequate education Conflict with religious, personal, or family values Societal taboos Speaker’s notes: Much like healthy sexual function, female sexual dysfunctions are complex and likely result from multiple factors, including the following psychological and biological factors: Physiological—medical complications, certain medications, and hormone loss or abnormality, such as in menopause Psychological—mood disturbances, previous traumatic experiences, stress, and drug and alcohol abuse Interpersonal relationships—lack of a partner, a partner’s medical condition, or other concerns such as children living at home Sociocultural influences—demographic characteristics, such as education level and socio-economic background

50 Sexual Desire Disorders
Hypoactive sexual desire disorder Absence of sexual fantasies, thoughts, and/or desire for, or receptivity to, sexual activity, which causes personal distress Sexual aversion disorder Phobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distress Speaker’s notes: These definitions resulted from the International Consensus Development Conference on Female Sexual Dysfunction, an interdisciplinary panel of international leaders convened by the American Foundation of Urological Disease in For hypoactive sexual desire disorder, the lack of desire, as measured by absence of markers of desire, including sexual thoughts or fantasies, must be persistent and cause distress. For sexual aversion disorder, the aversion to sexual contact must be persistent and cause personal distress. Reference: 1. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163: Basson R, et al. J Urol. 2000;163:

51 Sexual Arousal Disorder
Female sexual arousal disorder Inability to attain or maintain sufficient sexual excitement, causing personal distress, which may be expressed as a lack of subjective excitement, or genital (lubrication/swelling) or other somatic responses Speaker’s notes: This definition resulted from the International Consensus Development Conference on Female Sexual Dysfunction, an interdisciplinary panel of international leaders convened by the American Foundation for Urological Disease in This definition of female sexual arousal disorder recognizes that there are a wide range of physical and subjective reactions that characterize female sexual arousal. Reference: 1. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163: Basson R, et al. J Urol. 2000;163:

52 Sexual Orgasm Disorder
Female orgasmic disorder Delay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distress Speaker’s notes: This definition resulted from the International Consensus Development Conference on Female Sexual Dysfunction, an interdisciplinary panel of international leaders convened by American Foundation for Urological Disease in Female orgasmic disorder is the persistent difficulty, delay in, or absence of orgasm that must cause personal distress. Reference: 1. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163: Basson R, et al. J Urol. 2000;163:

53 B) Secondary anorgasmia:
Incidence: - Anorgasmia among non circumcised females: ranges from 5-10%. Anorgasmia among circumcised females 48%. Types of anorgasmia: A) Primary anorgasmia: Those who never had an orgasm under any sexual activity. - Early psychological trauma. - Social taboos. - Profound defect of personality. B) Secondary anorgasmia: 1- Situational anorgasmia: Transient causes include pregnancy, puerperium, fear of pregnancy, marital stress and dyspareunia 2- Coital anorgasmia: There is no orgasm during normal intercourse, but orgasm can be fulfilled during other alternatives as masturbation. It is failure to respond to normal stimulation. 3- Failure to receive stimulation: 1. Problems of sexual arousal during the excitement phase. 2. Failure of the husband to act at the excitement phase is a common problem.

54 Sexual Pain Disorders Dyspareunia Vaginismus
Genital pain associated with sexual intercourse Vaginismus Involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distress Noncoital sexual pain disorder Genital pain induced by noncoital sexual stimulation Speaker’s notes: These definitions resulted from the International Consensus Development Conference on Female Sexual Dysfunction, an interdisciplinary panel of international leaders convened by American Foundation for Urological Disease in The definitions for sexual pain disorders encompass pain associated with coital and noncoital stimulation. Reference: 1. Basson R, Berman J, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163: Basson R, et al. J Urol. 2000;163:

55 Dyspareunia Etiology: Primary dyspareunia: it is often psychological
inadequate stimulation or forced inhibition of arousal leading to inadequate vaginal lubrication and coital pain. Inadequate lubrication, may be secondary to improper or insufficient foreplay. Secondary dyspareunia: It is an acquired disorder, unrelated to the first coitus, and develops years later. Organic causes of dyspareunia include the following: Superficial dyspareunia: 1)Vaginal opening (introital lesions): inflammatory conditions (e.g., vestibulitis), infections (e.g. herpes, abscesses of Bartholin's glands or ducts). - Tight introitus: secondary to episiotomy, plastic repair of the vagina or radiotherapy.

56 2) Vulval skin lesions: hymenal tears, laceration of the fourchette, painful superficial ulcerations, congenital septum, rigid hymen, and circumcision scar tissue. Dermatologic disorders as lichen sclerosis. 3) Clitoris and urethra: Irritations and infections, and suburethral diverticulum. 4) Vagina: Infections as vulvovaginitis (trichomonas or candida). Menopausal involution with dryness and thinning of the vaginal skin. 5) Reactions to local contraceptives: 1- Improperly fitted or inadequately lubricated condoms. 2- Allergic reactions to the contents of contraceptive foams, jellies and condoms. 6) Radiation therapy for malignancy

57 (B) Deep dyspareunia: 1. Endometriosis. 2. Pelvic inflammatory disease. 3. Marked retroflexion of the uterus with ovaries prolapsed into the cul-de-sac "ovarian entrapment syndrome". 4. Shortening of the vagina after surgery. Diagnosis: The location and nature of the pain may help in the diagnosis: 1- Deep dyspareunia: pain on deep thrusting at intercourse may indicate lesions of the uterus and/or broad ligament. 2- Local examination: introital lesions and uterine displacement or other pelvic pathology.

58 Treatment: 1) Existing lesions or defects should be corrected. 2) Advice husband on posterior intromission to avoid pressure on the sensitive urethra. 3) If the vulva is swollen and painful, a wet dressing of dilute aluminum acetate solution may be applied locally. An analgesic, is indicated if the pain is severe.


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