Transcript The Anxiety Disorders Some Practical Questions & Answers

Sexual & Gender
Identity Disorders
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process1,2
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DLFAPA
November 8, 2012
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I want to speak frankly, not to offend. From now on, people will expect you to be an expert. Be one.
Please purchase and study, “The New Sex Therapy,” by Helen Singer Kaplan (1974).
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
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Most medical students have assumed this is a typo.
• 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.
What are some other common clinical
misperceptions about sexual functioning?
Everybody
30%
70%
Have Sexual Problems
• 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.
Don't
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.
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What disorders are included in this
category?
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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.
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
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• Sexual Desire Disorders
• Sexual Arousal
Disorders
• Orgasmic Disorders
• Sexual Pain Disorders
• Sexual Dysfunction due
to a [GMD]
Many sexual problems will turn out to be communication or relationship problems.
I worked with an older couple. The wife hated oral sex.
How do you treat the Sexual
Dysfunctions?
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Dual-sex therapy1
Specific techniques and exercises
Hypnotherapy
Behavior therapy
Group therapy
Analytically oriented sex therapy
Biological treatments
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.
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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.
• Psychotherapy sessions follow each period of
exercise.
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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.
What specific techniques and exercises
may be helpful?
• Graduated dilation is helpful for vaginismus.
• The “squeeze” technique is helpful for
premature ejaculation.1
• Masturbation may be helpful for male
hypoactive sexual desire disorder
• Masturbation using a vibrator may be helpful
for female orgasmic disorder.
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Here is a treatment protocol for successfully treating premature ejaculation.
What are some of the biological
treatments that are available?
• Sildenafil 50 mg and various “me-too” drugs have
revolutionized the treatment of ED.1
• 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.
• Surgical procedures have fallen out of favor.
• No widely accepted biological treatments for
female sexual dysfunction currently exist.
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newer drugs are usually very effective for antidepressant-induced sexual dysfunction. I treated a
couple who were very dissatisfied with his penile prosthesis.
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
functioning1
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• Some Diagnoses
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Exhibitionism
Fetishism
Frotteurism
Pedophilia
Sexual masochism
Sexual sadism
Transvestic fetishism
Voyeurism
Paraphilia NOS
is overwhelmingly a male problem. They are rarely self-referred. The court-mandated treatment of
exhibitionists is typical.
How do you treat paraphilias?
18 Year Olds
20%
80%
Have Been Molested
• 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.
• SSRIs have enjoyed limited
success.
Have Not
I wouldn’t accept these patients unless there was a “hammer.” I told them that the minimum treatment
was five years.
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What are Gender Identity Disorders?
Characterized by
strong and persistent
cross-gender
identification
accompanied by
persistent discomfort
with one's assigned
sex1
• Some Diagnoses
– Gender identity disorder
in children
– Gender identity disorder
in adolescents or adults
– Gender identity disorder
NOS
– Sexual disorder NOS
How do you treat gender identity
disorders?
Patients in Child Identity
Disorder Clinics
30
25
20
15
10
5
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Boys
Girls
• It is rarely successful if the
goal is to reverse the
disorder.
• Secondary depression or
anxiety is the usual focus.
• Surgical treatment is
definitive.
• Both sexes may be treated
with hormones in lieu of
surgery.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice 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.
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.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
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
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Phillip Roberts, DO
Jason Cheatham, DO
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