Presentation on theme: "The Human Sexual Response"— Presentation transcript:
1 The Human Sexual Response Amr Nadim, MDProfessor of Obstetrics& GynecologyAin 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: ExcitementPlateauOrgasm (climax)Resolution
6 Excitation:Vasocongestion: pelvic area receives more blood in general, in particular to genitals.Males:penile erectionscrotal sac thickens, elevatesFemales:vaginal lubricationglans clitoris enlarges (similar to penile erection)nipples erect (myotonia: muscle contraction)breasts enlarge (vasocongestioninner lips of vulva swell and open, change in colour (darker)upper 2/3rds of vagina balloonscervix and uterus stand up: tenting effectangle of cervical opening more receptive to spermBoth Sexes:sex flush (can happen later)heart rate, respiration rate gradually increasegeneralized myotonia
8 Plateau: Both males and females continue vasocongestion to max Heart rate, respiration rate and blood pressure continue to increaseCopious perspirationIncreased myotonia
9 Plateau (Cont’d) Females: orgasmic platform: outer third of vagina thickens, swells: condition sine qua non: without it, no orgasmtenting completeclitoris 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 prostatecontraction of urethra and penis: ejaculation
12 Orgasm: Females: contractions of orgasmic platform contractions of uterusseveral orgasms possible if stimulation continuesoxytocin
13 Orgasm: Both: very high heart rate, blood pressure and breathing intense myotonia
14 Health Benefits Associated With Orgasm General HealthAn orgasm at least once or twice per week appears to strength the immune system’s ability to resist flu and other virusesPain ReliefSome 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 SleepThe 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 RateMen who have more than five ejaculations per week during their 20s have a significantly lower rate of prostate cancer later in lifeMood EnhancementOrgasms increase estrogen and endorphins, which tend to improve mood and ward off depression in womenGreater Feelings of IntimacyThe 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 activationThe proportion and intensity of each varies with each orgasm.
17 EACH PHASE MUST BE FULLY COMPLETED IN ORDER TO REACH THE NEXT ONE ResolutionReturn to normal, muscles relax, breathing etc. back to normal, blood back to circulation from genitals.Malesrefractory periodEACH PHASE MUST BE FULLY COMPLETED IN ORDER TO REACH THE NEXT ONE
19 SOME GENDER DIFFERENCES Excitation:women slower:cultural expectations, socializationpregnancyIt 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 areaWomen (and some men):nipples, breasts, G-spotMen:prostateMany 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 declineMiddle Age:very noticeable, need direct stimulationOld Age:need lots of direct stimulationWomen:slower in teens, early 20sfaster 30’s onPlateau:capacity for longer with agesame, but never a big problem
25 Orgasmic: Resolution: Men: Middle Age: Refractory period increases intensity lessens from mid- to late 20sMiddle Age:really noticeableejaculate less volume, less forcefulResolution:Refractory period increases
28 PHYSIOLOGY OF THE SEXUAL RESPONSE Cognitive models:Kaplan’s triphasic model:sexual desirevasocongestionmuscular contractionWalen 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:arousalSympathetic:orgasmSpinal reflexes:erection and ejaculationErection: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 knownControversy 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:Testosteroneproduced by testes, ovaries and adrenal glandsimportant 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.
44 Prevalence of Sexual Complaints in Women 43% of women experienced a sexual problem32%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 yearsLaumann EO, et al. JAMA. 1999;281:
45 Comorbidity of Anxiety and Depression With Sexual Problems Increased association between anxiety or depression with sexual problemsOdds 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 problemsDunn 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 problemsOdds 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 dysfunctionReference: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 problemsDunn KM, et al. J Epidemiol Community Health. 1999;53:
47 Female Sexual Dysfunctions DesireLack of sexual desireDesire discrepancy with partnerAversion to sexual activityArousalDifficulties with physical and/or subjective sexual arousalDifficulties lubricatingDifficulties sustaining arousalOrgasmDifficulties experiencing orgasmPainPain with sexual activityDifficulties with vaginal penetration (anxiety, muscle tension)Lack of sexual satisfaction and pleasure
48 Categories of Female Sexual Dysfunction desire disordersHypoactive sexual desire disorderSexual aversion disorderSexualarousal disorderFemale sexual arousal disorderSexualorgasmic disorderFemale sexual orgasm disorderSpeaker’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:DyspareuniaVaginismusNoncoital sexual pain disorderSexual paindisordersBasson R, et al. J Urol. 2000;163:
49 Female Sexual Dysfunction PhysiologicalNeurological problemsCardiovascular diseaseCancerUrogenital disordersMedicationsFatigueHormonal loss orabnormalityPsychologicalDepression/anxietyPrior sexual or physical abuseStressAlcohol/substance abuseFemale SexualDysfunctionInterpersonalrelationshipsPartner performance and techniqueLack of partnerRelationship quality and conflictLack of privacySocioculturalinfluencesInadequate educationConflict with religious, personal, or family valuesSocietal taboosSpeaker’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 menopausePsychological—mood disturbances, previous traumatic experiences, stress, and drug and alcohol abuseInterpersonal relationships—lack of a partner, a partner’s medical condition, or other concerns such as children living at homeSociocultural influences—demographic characteristics, such as education level and socio-economic background
50 Sexual Desire Disorders Hypoactive sexual desire disorderAbsence of sexual fantasies, thoughts, and/or desire for, or receptivity to, sexual activity, which causes personal distressSexual aversion disorderPhobic aversion to and avoidance of sexual contact with a sexual partner, which causes personal distressSpeaker’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 disorderInability 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 responsesSpeaker’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 disorderDelay in or absence of attaining orgasm following sufficient sexual stimulation and arousal, which causes personal distressSpeaker’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 dyspareunia2- 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 intercourseVaginismusInvoluntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration, which causes personal distressNoncoital sexual pain disorderGenital pain induced by noncoital sexual stimulationSpeaker’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 uterusand/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.