Genitourinary Sexual Health

Normal Sexual Function and Dysfunction

• Sexual response cycle:
- Arousal: result of source of reflexogenic (touch) or psychogenic (fantasy) stimulation. In female, lubrication of vagina and swelling of clitoris. In male, penis becomes erect and tests draw closer to body
- Plateau: progression of arousal to orgasm. In female, vulva swells and vasodilatation of genitalia. In male, pre-ejaculatory fluid and vasodilatation of genitalia.
- Orgasm: muscular contraction of vagina in female and ejaculation in male with muscular contraction of glands and perineum.
- Resolution: return to baseline or unaroused state
- Refractory period: time delay before capacity to be re-aroused. Much faster in female than male.
• Kaplan 3 phase model: portrays the event of sexual function as desire, to arousal, to orgasm
- Problems: do not represent the reality for woman, e.g. assumes genital vasoconstriction is measure of arousal, possible disconnection between desire and orgasm.
• Female sexuality: very complex model.
- Emotional intimacy may be a stimulus
- Sexual neutrality may override desire, and stems from a woman’s duty to please or avoid offense
• Dangers of promoting sexual dysfunction education in woman:
- Place emphasis on sexual performance and function, instead of psychosocial aspects
- Promote insecurity
- Impose simple models/definition of sexuality while ignores woman’s complexity
- Discourage acts that don’t focus on genital stimulation
- Impetus for pharmaceutical companies
- Cause insurance company to ignore counselling
- Cause health practitioners and patients to ignore social factors
• Sexual problems:
- Impairments to physiology
- Impairments to human relations during sexual experience, e.g. difficulties or consequences for the ways people conduct them selves sexually (impact psychology)
• Non-physiological sexual dysfunction:
- Psychological: interpsychic barriers such as relationship and communications or intrapsychic problems such as beliefs, conflicts, shame, phobia etc
- Social: situational, e.g. needs romantic requirement
• PLISSIT model: a model of sexual counselling to allow suggestions of intervention for common sexual dysfunction to be communicated.
- Permission to talk
- Limited Information
- Specific Suggestions
- Intensive Therapy
• Female sexual dysfunction: causes maybe single or multifactorial
- Hyoactive sexual desire disorder: emotional and hormonal causes, mainly psychological
- Sexual arousal disorder: physiological, psychological
- Orgasmic disorder: primary (lifelong) or secondary (acquired)
- Sexual pain disorder: dyspareunia, vaginismus
• Physiology of FSD: neurogenic mechanisms
- VIP and NO control secretory processes
- NO and PDE5 both found in clitoral cavernosal smooth muscle
- Estrogen may affect sensory thresholds and regulate NO synthase
- Testosterone is required for sexual arousal, sensation and libido.
• Male sexual dysfunction:
- Libido: psychological vs physical
- Erectile difficulties: persistent inability, for at least 3 months, to obtain and maintain an erection sufficient for satisfactory sexual performance.
- Disorders of ejaculation: rapid, retarded or absent
• Low libido in men:
- Psychological: fatigue, situational factors and depression
- Physical: hypothyroidism, hypogonadism and decrease in testosterone
- Other: medication
• Erectile dysfunction: 52% men aged 40-70 has ED and prevalence increases with age
- Cause: organic such as hormonal, cavernosal, neurological or vasculogenic or psychogenic (central inhibition). Usually it is a mixture of the two
- Mechanism: fail to initiate due to spinal injuries, multiple sclerosis; failure to fill due to atherosclerosis and pelvic fracture, failure to store due to inadequate function of cavernosal smooth muscles.
• Management of ED:
- Diagnosis: investigations
- Co-morbidities: heart disease, depression, diabetes etc
- Lifestyle issues: smoking or alcohol abuse
- Education
- Personalized treatment
- Medication
• Rapid ejaculation: ejaculation occurs uncontrollably before intention
- Traditional theories: early masturbation, hypersensitivity, stimulating vagina, lack of alarm signal
- Traditional therapy: stop-start technique, anaesthetic spray
- Neurobiological approach: serotonin functions to inhibit ejaculation. Rapid ejaculation hence is due to decreased serotonin neurotransmission or hypofunction of 5-HT2C receptor with familial effects.
• Retarded ejaculation: persistent/recurring difficulty to ejaculate or experience orgasm following sufficient sexual stimulation. This can lead to personal and partner distress.
- Causes: age related, medication (e.g. alcohol, antericholinergics), habitual masturbation and diseases such as PVD, diabetic neuropathy
- Treatment: psychological approaches, medication and dose alteration, involvement of partner and accurate assessment needed.

Human Sexual Behaviour

• Sexuality: concerns the essences of being male or female and the various ways of expressing that alone in relationship and in society
• Sexual trichotomy:
- Sexual orientation: gender attraction
- Sexual identity: how individual identify themselves privately and publically (incongruence can occur)
- Sexual behaviour: sexual plans and actions
• National Survey of Sexual Attitudes and lifestyles 1990: face to face self administered interviews
• Result for heterosexual intercourse:
- Progressive reduction in age at first intercourse
- Increasing proportion of young woman having sex before consent age
- High chance of no contraception with first sex (great implications)
- Men due to curiosity while woman due to feelings and peer pressure
• Results for heterosexual partnership:
- Intercourse before 16 have high association with multiples partnership in life
- Higher social class has higher partner chance
- Multiple partnership decline with age
- Relationship forms usually between younger woman and older man
• Results for heterosexual practices:
- Small proportion have high frequency which peaks at mid-20’s
- 70% oral sex
- Anal sex with around 13% of group
- High prevalence of oral sex in younger age groups
• Results for sexual diversity:
- Same sex experience from 6.1% men and 2.4% women
- Men with no penetrative sex have greater sexual partners
- Proportion of simultaneous female and male partner was high
• Results for sexual attitudes:
- Stronger commitment to idea of heterosexual and monogamous union
- Premarital sex is nearly universal
• Results of physical health:
- Multiple relationships associated with smoking and alcohol consumption
- Attendance at STD clinic was strongly associated with number of heterosexual partners and homosexual sex contact
- 1/5 woman have history of miscarriage
- Likelihood of TOP increased markedly with increase number of heterosexual partners
• National Survey of Sexual Attitudes and lifestyles 2000:
• Early heterosexual experience: trends
- Increased proportion of men and women having sex before 16
- % of omen having first intercourse before 16 peaked after mid-90’s
- Increased use of condom (declined number of no contraception with first intercourse)
- Early age intercourse associated with pregnancy under 18 but not STI
- Low education associated with motherhood before age 18 (no abortions)
• Results of heterosexual partnership:
- Mean numbers of heterosexual partners have increase for both female and male
- Higher proportion cohabiting rather than marrying
- Greater condom usage but benefits offset by increases in number of partners
- Increased number of individuals reporting homosexual behaviour and increase report of gay sex
- Increase proportion of both oral and anal sex
• Explanation for change:
- Changing demographic structure and social attitudes
- Public awareness of HIV/AIDS and sexual health
- Homogenisation of behaviour and possibly attitudes across the whole country
- Changed methodology may increase people’s willingness to report personal information
• NZ partner relations Survey 1991: stratified random sample and telephone interview
- Progressive reduction of age of first sexual experience with males earlier than females
- Men have more partners than women (proportion of single partnership decreased)
- Age of establishment of regular partnership fallen
- Strong trend toward liberal lifestyles
- High prevalence of oro-penile sex with below 10% frequency of anal sex
- More likely to have regular partner in rurally town
- Sexual diversity: same-gender sex minimal compared to UK (2%)
- Sexual attitudes: most individuals worried of AIDS have reported changing behaviour and urban dwelling young adults with no report religious affiliations. Well educated are more liberal
- Physical health: multiple partners associated with infections with predictors of infection concentrated among young urban dwellers of liberal outlook
• Male call: study of 1852 NZ men who have sex with men to provide baseline data on sexual behaviour and describe HIV/AIDS knowledge in relation to sexual practices
- Sexual identity varies wit age group, relationship status and ethnicity
- Large proportion 75% with anal intercourse
- Minor proportions have engaged in bisexual sex, and 22% have one or more children
• GAPSS: Gay Auckland Periodic Sex Survey with written questionnaire
- 2-5 partners in the last 6 month
- Large proportion have sex with regular partner but less in an actual relationship with a men
- Relationship length spans mainly between 6 months to 5 years (around 50%)
- 56% in relationships longer than 6 month have had sex with another men

Sexually Transmitted Infections – Sexual; Behaviour and Other Risks

• Factors that influence STI incidence and distribution:
- Socioeconomic conditions
- Demographic factors such as birth rate, male to female sex ratio
- Sexual behaviour
- Cultural practices
- Prostitution
- Self-medication
• Risk markers: demographic factors causally linked to STI acquisition
- Marital status
- Rural-urban residence
- Socioeconomic status
• Risk factors: directly related to probability of acquiring an STI,
- sexual behaviour is the key determinant of viral STD but its incurable, e.g. number of partners, sexual practices
- health care behaviour are important and are curable ways of reducing STD incidence, e.g. no use of protection, late consultation for diagnosis, non adherence to drug therapy, douching (washing out vaginal secretion)
• Example of either category:
- Age and gender: indirectly correlates through sexual behaviour and likely prevalence of STD in sex partners and directly influence host susceptibility, e.g. prevalence of cervical ectopy is higher in younger women which contribute to risk of chlamydia and HIV
- Smoking
- Alcohol and drug abuse: risk modifiers
- Non-consenting sex
- Other STD: STD can act as a co-factor for another, e.g. create greater risk for HIV acquisition
• Importance of contraception:
- Barrier methods: reduce transmission of organism transmitted mainly between the columnar or transitional epithelium of the urethra and cervix (i.e. chlamydia, gonorrhoea)
- Condoms: strongly protective against organisms above and partly protective against which infect the squamous epithelium of the vulva and penis (i.e. HSV, HPV)
- Oral contraceptive: associated with increased susceptibility to cervical infection with chlamydia and gonorrhoea but decreased risk of pelvic inflammatory disease when cervical chlamydia is acquired.
• Impact of sexual behaviour: multi-facet including sexual experience, activity, age of first sex, number of partners, frequency of intercourse, types of sexual practice. Depending on the activity, a person may be a transmitter or a receiver.
- rate of change of partners is important as it increases risk of pre-symptomatic spread of infection
• Significance of urban dwelling: rural often have lower SES
- urban residents have higher opportunity to recruit casual partners than rural dwellers
- rural dwellers correlate with higher birth rates with population containing relatively more individual at ages groups most at risk of STD
- lower SES relates to lower rate of health care access despite higher need, lower education and lower recognition of symptoms
- Overall infection rats are higher, with delays in presentation and prolonged infection, high rates of complication.
• Problem of unemployment: leads to behaviours such as lower use of barrier contraception
• Risk reduction intervention: targets modifying variables more proximal to the point of STI acquisition
• Model of sexually transmission infection dynamics: incorporates the most important aspects of sexual behaviour risks:

- When Ro is greater 1, the incidence of STI in given population will increase
- Parameters are estimated per single exposure for several infections
• β: efficiency of transmission. Can be measured per single exposure or per multiple exposure and it is modified by virulence of the organism, the susceptibility of contacts and size of inoculum (number of organism), behaviour patterns.
• c: mean rate of partner change and will vary according to mixing pattern.
• D: duration of infectiousness and can be modified by different incubation period, host immune responses and behavioural response to infection.
• Sexually transmitted disease and characteristics:
- Genital herpes: breaches in mucosa and form blisters.
- Chlamydia: highest rate in NZ. Low level discharge and inflammation and peaks in adolescent. Low β, moderate D and low c
- Gonorrhoea: mucus and pus discharge. High β, very low D and low c
- Syphilis: increase in MSM. Leson on penis and mouth and mucus patches on tongue. High β, very low D, high c.
- HIV: very low β, very high D and c
- Non-specific urethritis: inflammation of urethra (similar to chlamydia)
• Sexual networks: array of sexual contacts and interactions specific to time and space. Different disease travel through different networks and present apparent demographic differences.
• Strategies of controlling STD:
- Syphilis: diseased, curative and secondary control
- Gonorrhoea: diseased (part carrier), curative, and both primary and secondary control
- Chlamydia: carrier (part diseased), curative, both primary and secondary control
- HSV2: carrier (part diseased), non-curative, primary control
- HIV: carrier, non-curative, primary control
- HPV: carrier, non-curative, primary control

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