Comportamentul sexual

Conf. Dr. Daniel Grigorie

Catedra de Endocrinologie,
UMF Carol Davila,
Institutul C.I.Parhon, Bucureti

Bucureti, 2013
ISTORIC
Kamasutra primul tratat explicit de sexologie umana
Kinsey variabilitatea practicilor sexuale la americani
Masters si Johnson : la ambele sexe exista raspunsuri
fiziologice previzibile dupa stimularea sexuala si au descris
ciclul raspunsului sexual normal pe baza caruia se clasifica
disfunctiile sexuale
Freud atribuie problemele sexuale ale adultului dificultatilor
maturarii sexuale in copilarie si dezvoltarii relatiilor parinte-
copil
1980 elucidarea mec. fizico-chimice ale erectiei, care este
consecinta relaxarii muschilor cavernosi si a cresterii fluxului
sg. penian, mediate de NO
ISTORIC
Studii epidemiologice releva prevalenta crescuta a
disfunctiei sexuale
OMS declara sanatatea sexuala ca pe un drept
fundamental
Comportamentul sexual
Srutul. Constantin Brncui
Orice activitate solitar, ntre dou persoane, sau
ntr-un grup care induce excitaie sexual
Encyclopedia Britannica
Care este diferit de comportamentul reproductiv,
definit ca orice activitate n scopul perpeturii speciei
O form de intimitate fizic ce poate avea drept scop reproducerea (un
posibil obiectiv al actului sexual), transcendena spiritual i/sau plcerea
oricrei activiti care aduce satisfacia sexual
Wikipedia
Orice aciune care conduce la recompens sexual. Recompensa sexual
presupune o stare afectiv pozitiv, obinut prin stimularea fizic a organelor
genitale sau reprezentare mental a unei asemenea stimulri
Anders Agmo, 2007
Terminologie (1)
Sex: caracteristicile biologice care definesc
persoanele ca femei sau brbai

Sexualitate: identiti i roluri sexuale, orientri
sexuale, erotism, plcere, intimitate, reproducere;
este experimentat i exprimat prin: gnduri,
fantasme, dorine, credine, atitudini, comportament,
practici, roluri i relaii; influenat de factori:
biologici, psihologici, sociali, economici, politici,
culturali, etici, legali, istorici, religioi i spirituali

Terminologie (2)
Sntate sexual - stare de bine fizic, emoional,
mental i social, legat de sexualitate, i nu numai
absena bolii, disfunciei sau infirmitii; abordare
pozitiv i cu respect a sexualitii, fr discriminare /
violen / constrngere.

Drepturi sexuale - recunoscute de legi, documente de
drept internaional: de a atinge standardele de
sntate legat de sexualitate, de a primi i mprti
informaii legate de sexualitate, educaie sexual,
respect pentru integritatea corporal, de a alege
partenerul, de a fi sau nu activ sexual, de a avea
copii, de a tri o via sexual sigur, plcut,
satisfctoare.

Dezvoltarea sexualitii (1)

Copilrie
n a doua jumtate a celui de-al treilea an de via ncepe
contientizarea asupra sexului i o identificare cu printele
de acelai sex
Adolescena
Modificri fizice rapide care duc la maturare anatomic
sexual i reproductiv
Adolescenii pot experimenta puternice impulsuri sexuale
care se consum prin masturbare sau experiene sexuale
Adult
Vrstnic

Dezvoltarea sexualitii (2)

Copilrie
Adolescena
Adult
Adncirea intimitii prin cstorie, apariia copiilor
Problemele de sexualitate pot s apar din lipsa
comunicrii ntre parteneri, monotonie, stereotipii
comportamentale, boli, etc.
Modificri caracteristice naintrii n vrst: scderea
interesului i activitii sexuale n special ntre 46 i 55 ani.
Vrstnic
Modificrile n esuturile androgen i estrogen dependente
continu pe msura naintrii n vrst
Frecvena actului sexual i a masturbrii scade, se
asociaz problemele de sntate, lipsa partenerului.

Funcia sexual normal
Beneficiile unei funcionri sexuale normale
mbuntirea imaginii, a respectului de sine
Menine o relaie bun cu partenerul
Crete motivaia pentru
adresabilitatea pentru alte probleme medicale
adoptarea unui stil sntos de via
Poate fi afectat de
Vrst
Menopauz
Patologia asociat

Controlul endocrin al
comportamentului sexual la brbat
Testosteronul este implicat n motivaia i interesul
sexual, n iniierea dorinei i a comportamentului
sexual
Castrarea i alte metode de reducere a nivelului de
androgeni reduc mult intensitatea comportamentului
sexual

Stimularea receptorilor androgenici este necesar i
suficient pentru exprimarea total a comportamentului
sexual la brbat

Nu exist date suficiente pentru a dovedi efectul
fazelor ciclului menstrual asupra comportamentului
sexual
Dup menopauz se nregistreaz un declin al vieii
sexuale, care nu ine neaprat de nivelul estrogenilor
Androgenii sunt importani n comportamentul sexual
al femeii

Controlul endocrin al
comportamentului sexual la femeie

Influenele hormonale asupra
dezvoltrii i functiei sexuale

Influene hormonale in utero
Hh. sexuali influeneaz diferenierea sexual
Hh. sexuali influeneaz tiparea sexual a
creierului n timpul dezvoltrii fetale (interaciuni
cu receptorii HT, orientarea sexual uman)
Influene hormonale i fiziologice asupra
ciclului rspunsului sexual
Testosteronul influeneaz dorina sexual
Modificrile vaginale din faza de excitaie sunt
mediate de eliberarea local a VIP (neuropeptid
secretat de nervi n peretele vaginal)
Ciclul rspunsului sexual la femeie
(Master & Johnson)
Rspunsul sexual feminin cuprinde patru stadii ale excitaiei,
marcate de modificri fiziologice i psihologice:
Excitaia = poate fi iniiat de o stimulare psihologic sau
fizic, este marcat de modificri emoionale precum i
creterea frecvenei cardiace, a respiraiei, ca i umezire i
lubrefiere vaginal datorit creterii fluxului sanghin;
Platoul= lubrifiere vaginal, frecvena cardiac i tensiunea
muscular pot crete pe msura continurii stimulrii; snii se
angorjeaz, apare erecia mameloanelor i uterul se
adncete;
Orgasmul= presupune contracii musculare sincronizate
vaginale, anale i abdominale, pierderea controlului muscular
involuntar i plcere intens;
Rezoluia= apare decongestionarea vaginului, a snilor,
relaxarea mameloanelor, reducerea frecvenei cardiace, a
respiraiei i a tensiunii arteriale.
Ciclul rspunsului sexual la brbat
(Master & Johnson)
Rspunsul sexual masculin cuprinde patru stadii ale excitaiei,
marcate de modificri fiziologice si psihologice:
Excitaia = poate fi iniiat de o stimulare psihologic sau
fizic, este marcat de modificri emoionale precum i
creterea frecvenei cardiace, a respiraiei, ca i tumescena
penisului i erecia, care poate fi parial pierdut i recptat
n aceast faz; scrotul se tensioneaz, testiculele sunt
ridicate;
Platoul= frecvena cardiac i tensiunea muscular pot crete
pe msura continurii stimulrii; crete circumferina
penisului, se nregistreaz mrirea n dimensiuni i ridicarea n
continuare a testiculelor; apare flash-ul sexual;
Orgasmul= presupune contracii sincronizate ale prostatei,
epididimului, ale canalelor deferente i ale veziculelor
seminale i senzaia de inevitabilitate a ejaculrii spermei;
Rezolutia= penisul pierde rapid vasodilatatia, cu scderea n
dimensiuni, coborrea testiculelor i relaxarea scrotului;
reducerea frecvenei cardiace, a respiraiei i a tensiunii
arteriale.
Modelul liniar al ciclului rspunsului
sexual
Adaptat dup Masters EH, et al. Human Sexual Response. Boston, Mass: Little Brown & Co., 1966; Kaplan HS. Disorders of
Sexual Desire and Other New Concepts and Techniques in Sex Therapy. New York, NY: Brunner/Mazel Publications; 1979.
Tensiune/
Excitaie
sexual
Timp
Dorin
Excitaie
Platou
Orgasm
Rezoluie
RASPUNSUL SEXUAL ESTE CIRCULAR LA
FEMEI
Poate incepe cu stimuli nu neaparat sexuali
Dorinta si excitatia co-exista si se potenteaza
reciproc
Excitatia subiectiva este mai importanta decat
congestia genitala
BALANTA ACTIVARE-INHIBITIE
In both men and women, the relationship between desire and
arousal is variable and complex; women are often unable
to separate the two

Bancroft and Graham proposed dual control theories for
sexual motivation in men and women. Their dual control
model envisions a balance between sexual activation
and sexual inhibition in an individual's brain, with this
balance determining whether sexual stimulation leads to
arousal
Factori stimulatori si inhibitori la femei
The excitation factors included sexual arousability, partner
characteristics, sexual power dynamics, smell, and setting.

The inhibition factors were :
- relationship importance (reflecting the need for sex to occur
within a specific type of relationship),
- concerns about sexual function (the tendency of worries and
distractions about sexual function to impair arousal), and
- arousal contingency (the potential for arousal to be inhibited
by some contextual/situational factor)
Factorii stimulatori sunt diferiti pe sexe
Men generally show greater responsiveness to visual sexually
arousing stimuli than women do.

In a study of surgically menopausal women who were sexually
active but were receiving no hormonal therapy. When these
women viewed erotica during functional magnetic resonance
imaging (MRI), they failed to display the brain activation
observed in premenopausal women or in themselves when they
were treated with testosterone and estrogen.
Neurotransmitatori si hormoni implicati
in dorinta/excitatie subiectiva
The role of testosterone in desire and arousal is better
documented in men than in women. In animal models, steroid
hormones modulate sexual arousal by directing synthesis of
the enzymes and the receptors for a number of
neurotransmitters, including dopamine, noradrenalin,
melanocortin, and oxytocin.
Systems that act within the hypothalamus and limbic regions
of the brain are involved in the process of arousal, attention,
and sexual behavior. It is thought that dopamine transmission
in the medial preoptic area and the nucleus accumbens
focuses the person's attention on sexual stimuli .
CAI INHIBITORII
Brain pathways for sexual inhibition include opioid,
endocannabinoid, and serotonin neural transmissions
feeding back to various levels of the excitatory pathways. It is
thought that the behavioral pattern stimulated by the
inhibitory pathways includes both sexual reward and satiety
refractoriness.
Low doses of opiates can have facilitatory effects, possibly
through actions in the ventral tegmental area to activate the
mesolimbic dopamine system. Exogenous opiates can induce
an intense feeling of pleasure which has been likened to
orgasm followed by a state of relaxation and calm.
Neurotransmitatori si hormoni implicati
in dorinta/excitatie subiectiva
Melanocortins are derived from pro-opiomelanocortin and
modulate sexual response through a specific receptor
subtype, the melanocortin-4 receptor. Administration of
melanocortin receptor agonists has been associated with an
increase in spontaneous erection in healthy men and in men
with ED and with increased desire, but not genital responses,
in women.
Oxytocin levels increase close to orgasm. This hormone is
known to be involved in pair bonding in some animal species,
but its relevance in humans is not known.
High levels of prolactin are associated with impaired sexual
function in men and women.

Genital Sexual Congestion and Arousal
Men and women differ substantially with respect to the
correlation between genital congestion and subjective sexual
arousal (excitement). Whereas subjective arousal is
typically concordant with genital congestion in men,
there is a poor correlation between subjective arousal
and measures of genital congestion in women. Also, in
contrast to men's assessment of their erections, women's
assessment of their degree of genital congestion is less
accurate.
It is thought that genital congestion in women is a prompt,
automatic reflex that occurs within seconds of an erotic
stimulus; it may not be deemed at all sexually arousing by the
woman, or it may even be deemed emotionally negativ
Physiologic Mechanisms of Penile
Erection
The medial preoptic area of the hypothalamus serves as
the integration site for the central nervous system control of
erections; it receives sensory input from the amygdala and
sends impulses to the paraventricular nuclei of the
hypothalamus and the periaqueductal gray matter. Neurons in
paraventricular nuclei project onto the thoracolumbar and
sacral nuclei associated with erections.
The parasympathetic input to the penis is proerectile,
and sympathetic input is mainly inhibitory.



Physiologic Mechanisms of Penile
Erection
Penile erection results from a series of biochemical and
hemodynamic events that are associated with activation of
central nervous system sites involved in regulation of
erections, relaxation of cavernosal smooth muscle,
increased blood flow into cavernosal sinuses, and
venous occlusion resulting in penile engorgement and
rigidity.

Normal penile erection requires coordinated involvement of
intact central and peripheral nervous systems, corpora
cavernosa and spongiosa, and normal arterial blood supply
and venous drainage.
Orgasmul
Orgasm is a brain event, triggered typically by genital stimulation but
also by sleep, stimulation of other parts of the body (including breast
and nipple), fantasy, certain medications
Orgasm is a subjective experience in both men and women, and it
has been difficult to determine an objective marker. In healthy men,
there is the associated ejaculation, and in both genders, there are
involuntary (reflexive) muscular contractions of the striated perineal
muscles
Positron emission tomography studies during orgasm have shown
largely similar brain activations and deactivations in both men and
women: activations mainly in the anterior lobe of the cerebellar
vermis and deep cerebellar nuclei and deactivations in the left
ventromedial and orbitofrontal cortex.
Hypoactive sexual desire disorder
Is persistent or recurrent deficiency (or absence) of sexual
fantasies and desire for sexual activity that causes marked
distress or interpersonal difficulty and that is not better
explained by another disorder, direct physiologic effects of a
substance (i.e., medication), or general medical condition.

A diagnosis of hypoactive sexual desire disorder is appropriate
only if the person reports distress or interpersonal difficulty
due to low sexual desire.
Low sexual desire is not necessarily pathologic; it may be an
appropriate adaptation to relationship and health-related
issues
Hypoactive sexual desire disorder
can result from androgen deficiency, use of medications (e.g.,
SSRIs, antiandrogens, gonadotropin-releasing hormone
[GnRH] analogs, antihypertensives, cancer chemotherapeutic
agents, anticonvulsants), systemic illness, depression and
other psychological problems, other causes of sexual
dysfunction, or relationship and differentiation problems.
Androgen deficiency is an important, treatable cause
of hypoactive sexual desire disorder and should be
excluded by measuring serum total testosterone
levels.
Hypoactive sexual desire disorder often coexists with other
sexual disorders, such as ED, and may develop as a
consequence of other preexisting sexual disorders.
Erectile dysfunction
previously referred to as impotence, is the inability to attain or
to maintain an erection sufficient for satisfactory sexual
intercourse.
Sexual dysfunction is a more general term that also
includes libidinal, orgasmic, and ejaculatory dysfunction, in
addition to the inability to attain or maintain penile erection.
The MMAS and NHSLS

investigations revealed a surprisingly
high prevalence of ED in men. ED significantly affects quality
of life of both the affected individual and his partner.
In one study, ED had a negative impact on the sexual life of
female partners, specifically on their sexual satisfaction and
sexual drive.

Erectile dysfunction
The risk factors for ED include age, diabetes
mellitus, hypertension, smoking, medication use,
depression, dyslipidemia, and cardiovascular
disease.

Advancing age is an important risk factor for ED in
men: less than 10% of men younger than 40 years
and more than 50% of those older than 70 have
ED.
In both the MMAS and the NHSLS, the prevalence
of ED increased with each decade of life.
Ejaculatory disorders
Ejaculatory disorders include premature ejaculation, delayed
ejaculation, retrograde ejaculation, anejaculation/anorgasmia,
and painful ejaculation.
Ejaculatory disorders are at least as prevalent and may be
even more prevalent than ED.
Premature ejaculation, defined as ejaculation associated
with lack of or poor ejaculatory control that causes distress in
one or both partners, is the most prevalent sexual disorder in
men 18 to 59 years of age.
Delayed ejaculation refers to inability to ejaculate in a
reasonable period that interferes with sexual or emotional
satisfaction and is associated with distress.
Tipuri de disfunctii sexuale feminine
Dorina
sczut
Orgasm
sczut
Stimulare
inadecvat
Excitaie
sczut
Disfuncie
sexual
Modelul circular al disfunciei sexuale
Sex dureros
Adaptat dupa Phillips NA, Int J Impot Res 1998; 10:S117-20
Contact sexual
nesatisfctor
Leiblum SR, Suppl Menopause Management, march/april 2004, 26-29
Patogenia disfunciei sexuale feminine
Anamneza sexual (1)
Contextul general:
Antecedente personale patologice
Prezena de boli / simptome cronice
Antecedentele menstruale, ginecologice &obstetricale
Sntatea mental
Uz / abuz de medicamente
Probleme fizice care interfer cu exprimarea sexualitii
Factori de risc pentru boli cu transmitere sexual
Self-percepia:
Efectele vrstei asupra stilului de via
Rata de satisfacie privind calitatea vieii
Percepiile legate de romantism i sexualitate
Importana sexualitii pentru femeie
Anamneza sexual (2)
Satisfacia sexual:
Disponibilitatea unui partener
Modificri recente n relaiile sexuale
Schimbri ale dorinelor sexuale
Tipul de activitate sexual preferat
Rata de satisfacie a relaiilor sexuale
Confideni pentru discuii pe teme generale sau
sexuale
Mediul:
Numrul de persoane din mediul de locuin
Ambient adecvat exprimrii sexualitii

Lipsa comunicrii medic-pacient
Pregtire insuficient a medicului, el
considernd aspectele sexuale mult mai
puin semnificative dect boala sa cronic
Jena pacientului de a aduce n discuie
problema sexualitii
Modelul PLISSIT pentru tratament
Permission
Limited Information
Specific Suggestions
Intensive Therapy

Permission
Creterea comunicrii (temeri, sentimente,
percepii)
Discuii privind modificri legate de vrst, stil
de via, boli
Rspuns la ntrebri legate de: vise erotice,
percepii sexuale, fantasme
ncurajarea acceptrii ideilor de sexualitate,
dorin, participare, satisfacie
Reasigurarea pacientului c activitaile i
dorinele lui sunt normale
Limited Information
Informare privind modificrile legate de
vrst (scderea libidoului datorat scderii
E/T, nevoia de exerciiu fizic zilnic)
Suport social puternic (ncurajarea participrii
la activiti sociale)
Literatura de informare asupra bolilor cronice
/ terapiei
Specific Suggestions
Recomandri privind poziii n timpul actului
sexual, care s evite dureri sau s asigure
adaptri la mobilitate limitat
Utilizarea unui lubrifiant la femei n PM
Tratament pentru candidozele genitale, inel
cu E pentru TH local
Msuri de protecie mpotriva bolilor cu
transmitere sexual


Intensive Therapy
Terapii complexe la un specialist n sexologie
Hipnoza, terapia de grup
Exemplu: probleme emoionale / psihice care
interfer exprimarea sexual: depresie,
alcoolism, cistocel, rectocel, etc.

Mituri privind sexualitatea i vrsta
femeii
Menopauza sau histerectomia = sfritul vieii sexuale
Activitatea sexual este neimportant pentru vrstnic
Interesul unei vrstnice pentru sex este perceput ca un
comportament anormal sau deviant
vrstnice nu pot contacta boli cu transmitere sexual
Recstorirea dupa pierderea soului este descurajat
Se accept ca vrstnici s aib partenere tinere, dar
reciproca este inacceptabil
vrstnice sunt neatractive fizic, deci nedorite sexual
vrstnice nu discut despre sexualitatea lor cu MF