1. Sexual & Gender Identity Disorders A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 A Presentation for the Students of Ohio University Heritage College of Osteopathic Medicine Kendall L. Stewart, MD, MBA, DLFAPA November 8, 2012 1 I want to speak frankly, not to offend. From now on, people will expect you to be an expert. Be one. 2 Please purchase and study, “The New Sex Therapy,” by Helen Singer Kaplan (1974).

2. What are some common clinical misperceptions about sexual functioning? Married people talk freely about their sexual preferences. Sex makes everything all right. The man is responsible for his woman's orgasm, and if she doesn't come three times he ain't worth spit. 1 You should go along with what your partner wants even if you don't enjoy it. Sex is 99% of marriage. You haven't had an affair until you've had sex. Oral sex is not real sex. 1 Most medical students have assumed this is a typo.

3. What are some other common clinical misperceptions about sexual functioning? If you're not getting it at home, it's OK to have an affair. Physicians and other counselors are comfortable talking about sex. Kids know everything there is to know about sex these days. 1 We now know everything there is to know about sex.We now know everything there is to know about sex 1 I once treated a young woman who was determined to remain celibate. Her boyfriend had a condom, but neither of them knew how to put it on.

4. What disorders are included in this category? Sexual Dysfunctions Paraphilias Gender Identity Disorders In DSM-5, the disorders in this category will likely be expanded into three separate categories, Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders.Sexual DysfunctionsGender Dysphoria Paraphilic Disorders

5. What are Sexual Dysfunctions? 1,2 characterized by disturbance in sexual desire and in the psychophysiological changes that characterize the sexual response cycle and cause marked distress and interpersonal difficulty Sexual Desire Disorders Sexual Arousal DisordersSexual Arousal Disorders Orgasmic Disorders Sexual Pain Disorders Sexual Dysfunction due to a [GMD] 1 Many sexual problems will turn out to be communication or relationship problems. 2 I worked with an older couple. The wife hated oral sex.

6. How do you treat the Sexual Dysfunctions? Dual-sex therapy 1Dual-sex therapy Specific techniques and exercises Hypnotherapy Behavior therapy Group therapy Analytically oriented sex therapyAnalytically Biological treatments 1 It is rare to see an isolated sexual dysfunction outside of troubled relationship context. A woman was very demanding of her husband, but she saw no relationship between her demands and his ED.

7. What is dual-sex therapy? The focus is on the marital unit instead of the individual. The couple “owns” the problem. A male and female therapy team meet with the couple to evaluate, educate and prescribe behavioral interventions. 1 Sensate focus exercises are the key intervention.Sensate focus exercises Psychotherapy sessions follow each period of exercise. 1 As always, motivation is a major issue. Few couples will take the time. Few troubled married people will Invest in marital therapy to the tune of a new wide-screen plasma TV. Marital therapy is straightforward.

8. What specific techniques and exercises may be helpful? Graduated dilation is helpful for vaginismus. The “squeeze” technique is helpful for premature ejaculation. 1“squeeze” technique Masturbation may be helpful for male hypoactive sexual desire disorder Masturbation using a vibrator may be helpful for female orgasmic disorder. 1 Here is a treatment protocol for successfully treating premature ejaculation.

9. What are some of the biological treatments that are available? Sildenafil 50 mg and various “me-too” drugs have revolutionized the treatment of ED. 1Sildenafil Treating the underlying mental disorder can help, but many of these drugs cause sexual dysfunction on their own. Vacuum pumps, constricting rings and self injection still have some role.Vacuum pumps Surgical procedures have fallen out of favor. No widely accepted biological treatments for female sexual dysfunction currently exist. 1 These newer drugs are usually very effective for antidepressant-induced sexual dysfunction. I treated a couple who were very dissatisfied with his penile prosthesis.

10. What are Paraphilias? Characterized by recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1 Some DiagnosesDiagnoses –Exhibitionism –Fetishism –Frotteurism –Pedophilia –Sexual masochism –Sexual sadism –Transvestic fetishism –Voyeurism –Paraphilia NOS 1 This is overwhelmingly a male problem. They are rarely self-referred. The court-mandated treatment of exhibitionists is typical.

11. How do you treat paraphilias? Insight-oriented psychotherapy is the most common approach. Motivation is an issue. 1 Negative behavior therapy has a role in some cases. Anti-androgens are controversial.Anti-androgens SSRIs have enjoyed limited success.SSRIs 1 I wouldn’t accept these patients unless there was a “hammer.” I told them that the minimum treatment was five years.

12. What are Gender Identity Disorders? Characterized by strong and persistent cross-gender identification accompanied by persistent discomfort with one's assigned sex 1 Some Diagnoses –Gender identity disorder in childrenGender identity disorder in children –Gender identity disorder in adolescents or adults –Gender identity disorder NOS –Sexual disorder NOS

13. How do you treat gender identity disorders? It is rarely successful if the goal is to reverse the disorder. Secondary depression or anxiety is the usual focus. Surgical treatment is definitive.Surgical treatment Both sexes may be treated with hormones in lieu of surgery.

14. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

15. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

16. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

17.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Jason Cheatham, DO Phillip Roberts, DO