Sexuality Throughout the Life Cycle

Abstract

There are few topics in medicine that blur the boundaries of science, religion, and morality more than sexuality. Less pathologization of gender nonconformity has taken place recently, as has been seen in changes in laws in the military, marriage equality, and changes in diagnostics in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Gender identity disorder is no longer used, being replaced in the DSM-5 with gender dysphoria; of note, the term “disorder” is not used. The nomenclature for “intersex” conditions and ambiguous genitalia has been modernized with the use of “disorders of sex development,” which is a more logical and applicable classification system, with greater clinical utility.

Appendices

Appendix A: Tables with Possible Answers to the Vignettes

Vignette 5.1: Baby Pat

Learning Issue Table 5.1

Facts	Hypotheses	Information needed	Learning issues
36-year-old woman who is 34 weeks pregnant and experiencing severe anxiety	Ambiguous genitalia can be seen in both congenital adrenal hyperplasia and in androgen insensitivity syndrome	Newborn physical and neurological examination	You meet with your patient and her husband and discuss possible reasons for the discrepancy and correcting any unrealistic fears that are worsening her anxiety
Amniocentesis performed at week 16 of pregnancy reveals normal results with an XY karyotype	Higher suspicion of androgen insensitivity because of the normal electrolytes and the ultrasound findings	Labs	Consider the common and uncommon disorders of sex development with a 46XY newborn and the present findings
Repeated prenatal ultrasound at week 34 of pregnancy reveals the fetus was female	How critical is it to assign a gender identity by a particular age?	Pediatric endocrinology consultation	Goals for parent education: address questions regarding future gender assignment, psychosexual development and potential medical problems
Uncomplicated delivery at 39 weeks gestation of a newborn girl with normal female genitalia	Which psychosexual issues need to be addressed prior to puberty?	Genetic testing	How is gender assigned for children with CAIS?
Ultrasound of the pelvic area reveals that there is no uterus and undescended testes are present	At what age or developmental stage will the child have powers of assent in order to contribute to decisions regarding treatment such as genital surgery?	How well defined is the “standard of care” regarding treatments related to gender assignment?	Family therapy is provided by the child psychologist with close monitoring of the child’s psychosexual development and considering at which later stage of cognitive development the issue of her diagnosis should be discussed with her
Pediatric endocrinology consult: genetic testing reveals CAIS	Consider the possible need for surgical removal of the testes before puberty because of the risk of cancer	How much family education needs to occur to facilitate an informed medical decision regarding the child’s treatment?	Additional goals of family therapy include, how could Pat be supported to make some of her own decisions regarding treatment sometime during adolescence
After a few family sessions with the parents, child psychologist and yourself, the parents have decided to rear Baby Pat as a girl	What is the role of the family’s values in directing medical interventions?		Depending on Pat’s preferences and anatomical findings, a discussion will be needed regarding options with genital surgery and hormone treatment
You meet with the parents, child psychologist, and Pat, who is now 9 years old
There has been an ongoing discussion with the parents recently as to when to discuss the diagnosis of CAIS with Pat
Family and treatment team agree that Pat should make some of her own decisions regarding treatment sometime during adolescence

1. CAIS complete androgen insensitivity syndrome

Vignette 5.2: Mike

Learning Issue Table 5.2

Facts	Hypotheses	Information needed	Learning issues
Mike, a 6-year-old boy who is brought in by his mother because of “behavior problems in school that might cause him to get kicked out”	Normal childhood development	Comprehensive behavioral health evaluation including information from youth, family, and school staff	You talk to Mike and his mother, Mike conveys regret over what he had done
According to the principal, he once exposed his penis to a group of his male and female classmates in the playground	Children become naturally curious about matters pertaining to sex and sexual organs	Comprehensive medical evaluation	You meet with school staff
Several parents lodged complaints that they would pull their children out of this school if the teachers could not contain the “immorality” of “other troubled children”	Developmentally normal behaviors include sexually themed play, exploration of one’s own body and the bodies of others, and enactment of adult sexual roles (e.g., being mommy or daddy), often within the safety of the family		You learn that, while he may have seen some kissing and adult sitcom shows while being babysat by a teenage cousin and her boyfriend a few months ago, he has not had any other exposure to inappropriate sexual material
He also tends to make “lewd comments” about people depicted in bathing suits in various magazines	Clinician should certainly consider other conditions and situations that may predispose to behaviors that are either quantitatively or qualitatively inappropriate for the given age of development		You meet with Mike’s mother and teaching staff and provide counseling about developmentally appropriate supervision in home and school settings and refocusing on developmentally appropriate tasks
	Can you consider examples of behavior that suggest either inappropriate exposure to sexual activity or other psychopathology
	Hypotheses to investigate include abuse, neglect, insufficient financial resources, domestic violence, inadequate supervision, and methods of discipline

Vignette 5.3: Mary Jane

Learning Issue Table 5.3

Facts	Hypotheses	Information needed	Learning issues
Mary Jane, a 14-year-old high school freshman who is brought in by her mother, who requests that Mary Jane be tested for HIV and “anything else that can be sexually transmitted,” placed on the “birth control shot,” and given “that new cervical cancer vaccine and anything else that can prevent sexually transmitted diseases”	Adolescent	Comprehensive behavioral health and medical history	Confidentiality
Mary Jane’s mother learned that she slept with a boy classmate at band camp and is now worried that she will catch something from “being promiscuous”	Development	Medication history	Special areas of interest for the interview with adolescence patients
Mary Jane explains that she previously had never had sexual intercourse, other than having “experimented” with fondling a close female friend who is lesbian (even though she herself is “straight”)	Sexual identity and activity	Routine labs	Statistics suggest that sexual activity, including intercourse, is common in adolescence, and should prompt the clinician to assist youth in preventing sexually transmitted disease and unwanted pregnancy
She denies ever having had any other sexual experiences. Mary Jane comes from a “traditional family” that, she believes, would not otherwise condone any premarital sexual activity or any homosexual behaviors	Normal sexual activity	Sexual history	Offer blood testing for HIV and syphilis
	Antisocial or delinquent behavior	Physical exam—sexual maturity rating (SMR) stage 4	Insure that hepatitis B immunizations are up-to-date and administer the first of the human papillomavirus vaccine series
	Alcohol and substance abuse	Pelvic exam with Papanicolau smear and cultures for gonococcus and chlamydia	Offer blood testing for HIV and syphilis
	Suicidal ideation or behavior, including non-suicidal self-injury		Counsel her on effective methods of preventing sexually transmitted diseases, including abstinence
	Risks of coercion, sexually transmitted disease, and pregnancy

Vignette 5.4: Phil Robertson

Learning Issue Table 5.4

Facts	Hypotheses	Information needed	Learning issues
Mr. Phil Robinson is a 58-year-old male with a history of panic disorder and hypertension	Normal sexual development of older adult	Psychiatric and medical history	You work to optimize his medication regimen and insure that he has no new medical problems
For the past 6 months, he and his 49-year-old wife have had sex less and less frequently	Characteristics of the human sexual response cycle	Physical exam	You provide education to him and his wife about the various factors that can affect the sexual response cycle
Recently had more difficulties getting “in sync” with each other, either she has little sexual interest (which she relates to “premenopause”) or she is sexually interested but he has difficulty maintaining an erection	Erectile disorder in Mr. Robinson and the possibility of a female sexual interest/arousal disorder in his wife	Medication history	You encourage Mrs. Robinson to follow-up with her physician
He denies any past history of sexual difficulties, other than what he reports as “premature ejaculation” earlier in his adult life	Health conditions	Routine labs	In the meantime, you encourage them to focus on enjoying emotional and physical closeness with each other, with a de-emphasis on sexual intercourse
Mr. Robinson is taking a beta-blocker for hypertension and a serotonin-selective reuptake inhibitor along with a benzodiazepine for panic disorder	Medications he may be taking
A few months later, he is happy to report that they have enjoyed their sex life once again	Psychosocial stressors and anxiety around sexual intercourse
	The increased anxiety symptoms he had been having around that time (hence the dose increase) may have played a more important role and may have contributed to what he feels may be a “vicious cycle” of performance anxiety around sexual intercourse

Appendix B: Answers to Review Questions

Answers

• 1. d

• 2. c

• 3. a

• 4. b