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The risk of this approach is that if hormone levels (particularly testosterone) have not reached the target range coke causes erectile dysfunction super avana 160mg otc, but progress is judged as appropriate based on clinical exam erectile dysfunction ayurvedic drugs purchase discount super avana line, a suboptimal degree of feminization is possible age related erectile dysfunction causes buy generic super avana 160 mg, and the presence of supraphysiologic levels would also be obscured erectile dysfunction statistics cheap super avana 160 mg amex. Conversely, Endocrine Society guidelines recommend monitoring of hormone levels every 3 months. A prospective study of transgender women taking 4mg/day divided dose oral estradiol or 100mcg transdermal estradiol, plus 100-200mg/day divided dose spironolactone found that all women achieved physiologic estradiol levels, though only 2/3 of the women achieved female range testosterone levels. Regardless of initial dosing scheme chosen, dosing may be titrated upwards over 3-6 months. Check estradiol and June 17, 2016 31 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People testosterone levels at 3 and 6 months and titrate dose accordingly. For those patients using spironolactone, check renal function and K+ at 3 months and 6 months, then q 6-12 months. While laboratory monitoring of hormone levels may seem complex, it is of similar difficulty to the monitoring of other similarly complex lab-monitored conditions managed by primary care providers, such as thyroid disorders, anticoagulation, or diabetes. Once hormone levels have reached the target range for a specific patient, it is reasonable to monitor levels yearly, or only as needed as described below. As with other situations involving maintenance of hormone therapy (menopause, contraception), annual visits are sufficient for transgender women on a stable hormone regimen. Other reasons for measuring hormone levels in the maintenance phase include significant metabolic shifts such as the onset of diabetes or a thyroid disorder, substantial weight changes, subjective or objective evidence of virilization, or new symptoms potentially precipitated or exacerbated by hormone imbalances such as hot flashes or migraines. Increased frequency of office visits may also be useful for patients with complex psychosocial situations to allow for the provision of ancillary or wraparound services. Current Endocrine Society recommendations include the measurement of only total testosterone and estradiol. This is consistent with Endocrine Society recommendations that only total testosterone be monitored in non-transgender men being managed for testosterone deficiency, except in cases of borderline testosterone levels. However, since testosterone is of particular concern is insuring maximal feminization, the calculation of bioavailable testosterone in transgender women may still be of value. As such in cases of patient concern or persistent virilized features in the presence of a female-range total testosterone, calculation of the bioavailable testosterone may help fine tune hormone regimens for optimal effect. Interpretation of laboratory results requires special attention in the context of transgender care. However, these specific ranges may vary between different laboratories and techniques. Furthermore, the interpretation of reference ranges supplied with lab result reports may not be applicable if the patient is registered under a gender that differs from their intended hormonal sex. For example, a transgender woman who is still registered as male will result in lab reference ranges reported for a male; clearly these ranges are not applicable for a transgender woman using feminizing hormone therapy. Hormone levels for genderqueer or gender nonconforming/nonbinary patients may intentionally lie in the mid-range between male and female norms. Providers are encouraged to consult with their local lab(s) to obtain hormone level reference ranges for both “male” and “female” norms, and then apply the correct range when interpreting results based on the current hormonal sex, rather than the sex of registration. Monitoring estradiol levels Historically estrogen levels have been monitored using the total serum estradiol. The 2009 Endocrine Society Guidelines recommend monitoring serum estradiol and maintaining levels at the June 17, 2016 32 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People mid-cycle range for non-transgender women. There is no evidence that higher estradiol levels in patients with adequate androgen suppression results in additional feminization or breast development. Maintaining estrogen levels in the physiologic range for menstruating non-transgender women minimizes risks and side effects, and makes sense clinically. Note that the use of conjugated estrogens (Premarin®) or ethinyl estradiol (found in most combined oral contraceptives) are not accurately measured by estradiol assays and will typically result in low measured levels. In patients who have been using self-administered conjugated estrogens, or ethinyl estradiol, it is reasonable to check a total estrogens level, which may provide a more accurate estimate in these cases. There is some evidence that the use of oral estradiol results in higher serum levels of estrone due to first pass hepatic metabolism, as compared to parenteral forms. Monitoring testosterone levels Testosterone levels can be difficult to measure in non-transgender men due to rapid fluctuations in levels, relating to pulsatile release of gonadotropins, with higher levels in the morning hours. Monitoring hormone levels in patients using injected estrogen Pharmacokinetic studies of injected estrogen have been limited. Two earlier studies only examined single-dose pharmacokinetics and are therefore unable to be applied to steady-state dosing. When measuring hormone levels in patients using injected forms of estradiol, a mid-cycle level is often sufficient, however if the patient is experiencing cyclic symptoms such as migraines or mood swings, peak (1-2 days post injection) and trough levels of both estradiol and testosterone may reveal wide fluctuations in hormone levels over the dosing cycle; in these cases, consider changing to an oral or transdermal preparation, or reducing the injection interval (with concomitant reduction in dose, to maintain the same total dose administered over time). A single study suggests similar pharmacokinetics when estradiol is injected subcutaneously, rather than intramuscular. Several factors contribute to these differences, bone mass, muscle mass, number of myocytes, presence or lack of menstruation, and the erythropoetic effect of testosterone. While transgender women do not menstruate, those with female-range hormone levels will lack the erythropoetic effects of male-range testosterone, and it may be reasonable to use the female-range lower limit of normal when interpreting H&H. Conversely, the lack of menstruation, and potential for pulsatile undetected androgen activity in those with retained gonads make it reasonable to use the male-range upper limit of normal for H&H. Using the male-range upper limit of normal for alkaline phosphatase and creatinine may also be appropriate for transgender women due to retained bone and muscle mass or myocyte counts, respectively. This is of particular importance in transgender women using spironolactone who are registered as female, and may have a lab result flag showing an abnormal elevated creatinine. Lower and upper limits of normal to use when interpreting selected lab tests in transgender women using feminizing hormone therapy Lab measure Lower Limit of normal Upper Limit of normal Creatinine Not defined Male value Hemoglobin/Hematocrit Female value Male value Alkaline Phosphatase Not defined Male value Individualized dosing based on patient centered goals Some patients may desire limited hormone effects or a mix of masculine and feminine sex characteristics. Examples include retention of erectile function with otherwise maximum feminization, or minimal feminizing effects with the exception of body or facial hair elimination or breast growth. While manipulation of dosing regimens and choice of medication can allow patients June 17, 2016 34 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People to achieve this goal, it is important to have a clear discussion with patients regarding expectations and unknowns. Specifically, it is not possible to select in advance an exact hormone regimen that will predictably allow patients to arrive at a specified configuration of sex characteristics. Furthermore, individual genetic and physiologic variation can result in wide variations in both blood levels and response to therapy between different individuals using the same route and dose. At the same time, response to hormone therapy is also individualized and measures such as breast growth are variable in both degree and time course. Likely predictive factors of speed and degree of feminization include genetics, age at initiation of therapy, and body habitus. All transgender women who smoke should be counselled on tobacco risks and cessation options at every visit. Many transgender women may be unable or unwilling to quit smoking; this should not represent an absolute contraindication to estrogen therapy. After an in depth and careful informed consent discussion, it is reasonable to prescribe estrogen using a harm reduction approach, with a preferred route of transdermal estrogen. Loss of erectile function: Sildenafil (Viagra) and tadalafil (Cialis) can be used for preservation of erectile function at any stage or with any feminizing hormone regimen, in consideration of the typical contraindications and precautions when using this class of medication. It is reasonable check both total and bioavailable testosterone levels, and consider reduction of androgen blockade to allow an increase in testosterone, depending on patient goals. This study found no correlation between sexual desire and testosterone levels in the transgender women, though a significant correlation was found between hormones and desire in non-transgender women. Post-gonadectomy: Since estrogen dosing should be based on physiologic female levels, no reduction in estrogen dosing is required after gonadectomy. Some patients may choose to use a lower dose, which is appropriate as long as dosing is adequate to maintain bone density. Due to higher levels of co-occurring conditions in older individuals, there may also be higher risk of adverse effects. Nevertheless a large number of women have started hormones at advanced ages and safety and satisfaction have been reported as acceptable. Expected effects of this may be similar to non-transgender women experiencing menopause. Transgender women who retain their gonads but withdraw hormone therapy may experience return of virilization. A discussion of the pros and cons of this approach, with individualized and shared decision making is recommended. Pituitary adenoma (prolactinoma) and galactorrhea: Prolactin elevations and growth of pituitary prolactinomas are theoretical risks associated with estrogen therapy; several cases have been reported.
However erectile dysfunction and diabetes treatment order super avana 160 mg mastercard, loss of movement or sensation does not change the fact that you are a desirable sexual being erectile dysfunction specialist super avana 160mg with mastercard. You are more likely to jack3d causes erectile dysfunction order cheap super avana feel desirable and want to erectile dysfunction doctor in miami discount super avana online mastercard fully express your sexuality if you understand your body and feel comfortable with yourself and your personal identity. The contents of this fact sheet are based on research evidence and/or Here are a few ways dating may be different. Be ready editorial team of experts from the to respond in a way that is comfortable for you. Spinal Cord Injury Model Systems, • You may need to balance your dating schedule with a caregiver’s schedule. If so, you may Living, and Rehabilitation Research need to talk with them about setting up guidelines for bringing a date home, privacy, and (See http://www. This includes an increase in heart rate, blood pressure, and breathing rate, and can include an increase in blood flow to the genitals to ready your body for sex. Sexual arousal after injury One or both of your pathways for arousal may be blocked. You might also enjoy touching in areas like your neck, ears, nipples, and inner thighs. Often times, spasticity medications, pain medications, or antidepressants are contributing factors. If cannot, talk to your health professional about other options, which might include a constricting ring, vacuum suction device, injection of medications in to the penis, or a surgically implanted penile prosthesis. An orgasm is a reflex response of the nervous system that feels good and relaxes you. Remember, sexual activity can be great fun with or without orgasm, but here are some potential options. If that happens, stop activity, check your blood pressure, and ask your doctor to review your medications to see if they can be adjusted. You consider the demands and challenges of parenting and how you might manage them. Here are other facts to consider when deciding whether or not you want to have children. You can naturally become pregnant, carry, and deliver a baby once your period returns. Contact your doctor if your period does not return with a few months after injury. The syringe can be inserted in to your partner’s vagina, and the semen is slowly injected. This fact sheet is only a starting point to begin to understand how your body might change after injury. If not, you and your partner can be creative and open to exploring new ways to find sexual satisfaction. Using humor and being playful are keys to having a more interesting, enjoyable and mutually pleasurable experience. This involves self-awareness and possibly self-exploration to get a clear sense of what you want or need sexually. Talking about sex can be difficult, so you will want to communicate in a way that makes both you and your partner feel comfortable. The goal is to talk about any issues or concerns and work together to solve problems and resolve concerns. Listen and be open to your partner’s response, just as you would like your partner to do for you. Listening to your partner can help resolve issues in a way that satisfies both partners. However, you and your partner should be able to manage issues as you continue to communicate, listen, and remain flexible. Do everything you can to keep the role of the caregiver separate from that of a romantic partner. Learn to do as much as you can with your self-care and other daily living activities. Keeping these roles separate will help you to avoid confusing and blurring the two roles. They can provide you with accurate information, treat you with respectful, and ensure confidentiality answering your questions. Authorship Sexuality & Sexual Functioning After Spinal Cord Injury was developed by Marcalee Alexander, M. Disclaimer: This information is not meant to replace the advice of a medical professional. You should consult your health care provider regarding speci?c medical concerns or treatment. Cardiovascular leakages and diabetes are the major factors that are responsible for poor sexual performance and reproductive health. This review is aimed at reviewing the pharmacological and phytochemical properties of various medicinal plants used for the improvement of sexual performance and virility. Psychotherapeutic, pharmacological and traditional methods have been used in the management of poor sexual performance and virility. Drugs such as papaverin, alprostaldin and stimulants like apomorphine have been used to improve sexual health. The aphrodisiac activities of plants may be as result of their bioactive constituents. This research has therefore shown that the reviewed plants can be used for the management of poor sexual performance and virility. Sexual health requires a positive approach to human sexuality and an understanding of the complex factors that shape human sexual behaviour [1]. Whether the expression of sexuality leads to sexual health and well-being or to sexual behaviour that put people at risk; it is determined by these factors which could also result to sexual and reproductive ill health [2]. Sexual performance anxiety is a cisgender and very real, upsetting, legitimate health and significant issue. It is no secret that our patriarchal culture at large does not understand women sexuality. Because of all the unnecessary and damaging “mystery’’ surrounding female sexual desire, performance anxiety for women is not often discussed because we don’t really know how to discuss it. For men, sexual performance is an ability to maintain an erection throughout the period of sexual intercourse and this ability of men’s penis to stay erected hard for the duration of sex is a guarantee for a climax. The production of these hormones in the body causes poorly wet or dry vagina, highly tense vagina muscles which lead to difficult penetration or nearly impossible penetration and poor desire for sex [3]. Poor sexual performance is a major factor that must be overcomed for lasting peace in some marriages. Sexuality is a central aspect of being human throughout life and encompasses sex, gender and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviour, practices, roles and relationships. It is also important to note that while sexuality can include all of these dimensions, not all of them can be experienced or expressed. Sexuality is influenced by the interaction of biological, social, economic, political, cultural, ethical, historical, and religious and spiritual factors [4-5]. Sexual health requires a positive and respectful approach to sexuality and sexual relationships as well as the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination and violence. Sexual performance is naturally important to men due to their ego and instincts to procreate. The ability to satisfy a woman, the size of a man’s penis which is often though wrongly associated with sexual ability is what makes up every man. Poor sexual performance causes low self-esteem and due to natural sexual instinct, humans are able to attract suitable mates and procreate. Sexual performance in male sex is fundamental in the following areas; the ability to satisfy a woman and give her orgasms and the ability to impregnate a woman [6].
Desc: neurogenic 0% erectile dysfunction clinic order 160 mg super avana with amex, post-prostatectomy 0% best erectile dysfunction pills treatment super avana 160mg online, Rx: Placebo Copyright © 2005 American Urological Association Education and Research erectile dysfunction in 20s purchase 160mg super avana fast delivery, Inc erectile dysfunction interesting facts quality super avana 160mg. Desc: organic 59%, psychogenic 15%, mixed 26%, Rx: Grp: 1 All patients getting Sildenafil age: duration: Pts: 163 Pt. Desc: mixed 100%, Rx: sildenafil [25,100]T Grp: 90 Al placebo patients age: duration: Pts: 166 Pt. Desc: mixed 100%, Rx: Placebo [25,100]T Copyright © 2005 American Urological Association Education and Research, Inc. Desc: organic 77%, psychogenic 9%, mixed 13%, Rx: Grp: 1 25 mg sildenafil age: duration: Pts: 102 Pt. Desc: coronary heart disease 100%, Rx: sildenafil [50,100]T Grp: 2 other cardiac conditions age: duration: Pts: 2 Pt. Desc: lower limb arteritis 100%, Rx: sildenafil [50,100]T Grp: 4 diabetes age: duration: Pts: 2 Pt. Desc: Rx: sildenafil [50,100]T Copyright © 2005 American Urological Association Education and Research, Inc. Desc: hypertension 100%, Rx: sildenafil [50,100]T Grp: 5 hypertension age: duration: Pts: 24 Pt. Desc: hypertension 100%, Rx: sildenafil [50,100]T Grp: 6 >20 cigarettes/day age: duration: Pts: 15 Pt. Desc: >20 cigarettes/day 100%, Rx: sildenafil [50,100]T Grp: 7 high cholesterol age: duration: Pts: 17 Pt. Desc: post-prostatectomy 88%, rectal amputation 12%, Rx: sildenafil [50,100]T Grp: 9 neurologic disorder age: duration: Pts: 7 Pt. Desc: Rx: sildenafil [50,100]T Grp: 12 major cavernous leak age: duration: Pts: 24 Pt. Desc: post-prostatectomy 100%, non nerve sparing 13%, unilateral nerve sparing Rx: sildenafil [50,200]T 27%, bilateral nerve sparing 60%, Discont. Desc: bilateral nerve sparing 100%, Rx: sildenafil Grp: 2 unilateral nerve sparing prostatectomy age: duration: Pts: 23 Pt. Desc: unilateral nerve sparing 100%, Rx: sildenafil Grp: 3 no nerve sparing prostatectomy age: duration: Pts: 11 Pt. Desc: organic 100%, neurogenic 100%, Rx: Placebo [25,50]sildenafil [25,50] Lost: 0%// Discontinued: 0%// Grp: 1 25 mg Sildenafil age: (19,35) duration: Pts: 8 Pt. Desc: organic 100%, neurogenic 100%, Rx: sildenafil 25 Grp: 2 50 mg Sildenafil age: (19,35) duration: Pts: 8 Pt. Desc: organic 100%, neurogenic 100%, Rx: sildenafil 50 Grp: 90 25 mg placebo age: (19,35) duration: Pts: 8 Pt. Desc: organic 100%, neurogenic 100%, Rx: Placebo 25 Grp: 91 50 mg placebo age: (19,35) duration: Pts: 8 Pt. Desc: organic 100%, spinal cord injury 100%, Rx: sildenafil [25,100]T Discontinued: 3%/6/175 Discont. Desc: organic 100%, spinal cord injury 100%, Rx: sildenafil [25,100]T Grp: 90 Patients receiving placebo with spinal cord age: 38(19,63) duration: 11(0. Desc: organic 100%, spinal cord injury 100%, Rx: Placebo [25,100]T Discontinued: 2%/4/174 Discont. Desc: organic 100%, spinal cord injury 100%, Rx: Placebo [25,100]T 10223 Dinsmore, W. Sildenafil citrate (Viagra) in erectile dysfunction: near normalization in men with broad-spectrum erectile dysfunction compared with age- matched healthy control subjects. Desc: organic 21%, psychogenic 40%, mixed 39%, diabetes 12%, Rx: sildenafil [25,100]T Discontinued: /3/ Discont. Desc: organic 20%, psychogenic 39%, mixed 37%,"other/unknown" 4%, Rx: Placebo [25,100]T diabetes 7%, Discontinued: /11/ Discont. Desc: Rx: sildenafil 50 Grp: 90 All patients all phases - placebo - all with age: 37(21,49) duration: 7. Desc: spinal cord injury 100%, Rx: Placebo 50 Lost: /1/ Copyright © 2005 American Urological Association Education and Research, Inc. Sildenafil for treatment of erectile dysfunction in men with diabetes: a randomized controlled trial. Desc: diabetes 100%, Rx: sildenafil [25,100]T Grp: 90 Placebo age: 57(27,79) duration: 5. Desc: diabetes 100%, Rx: Placebo [25,100]T Copyright © 2005 American Urological Association Education and Research, Inc. Desc: diabetes 100%, Rx: sildenafil Lost: /0/ Grp: 90 placebo age: duration: Pts: 21 Pt. Sildenafil in the treatment of erectile dysfunction: efficacy in patients taking concomitant antihypertensive therapy.. Desc: Rx: sildenafil [5,100] Grp: 2 No antihypertensives + sildenafil age: duration: Pts: Pt. Desc: Rx: sildenafil [5,100] Grp: 90 On antihypertensives + placebo age: duration: Pts: Pt. Desc: Rx: Placebo [5,100] Grp: 91 No antihypertensives + palcebo age: duration: Pts: Pt. Efficacy and safety of oral sildenafil in the treatment of erectile dysfunction: a double-blind, placebo-controlled study of 329 patients.. Desc: organic 55%, psychogenic 14%, mixed 31%, diabetes 8%, post- Rx: sildenafil [25,100]T prostatectomy 9%, hypertension 24%, hyperlipidemia 15%, Lost: /3/163 Discont. Desc: organic 63%, psychogenic 16%, mixed 22%, diabetes 11%, post- Rx: Placebo [25,100]T prostatectomy 11%, hypertension 28%, hyperlipidaemia 15%, Lost: /2/166 Discont. Efficacy and safety of fixed-dose oral sildenafil in the treatment of erectile dysfunction of various etiologies.. Desc: organic 82%, psychogenic 3%, mixed 15%, diabetes 21%, Rx: sildenafil [25,100]T Discontinued: /7/ Discont. Desc: organic 80%, psychogenic 5%, mixed 15%, diabetes 19%, Rx: Placebo [25,100]T Discontinued: /12/ Discont. Desc: organic 64%, psychogenic 4%, mixed 32%, diabetes 100%, Rx: sildenafil [25,100]T Discont. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate. Desc: organic 81%, psychogenic 9%, mixed 10%, diabetes 22%, Rx: sildenafil [25,100]T Discont. Desc: organic 83%, psychogenic 8%, mixed 9%, diabetes 25%, Rx: Placebo [25,100]T Discont. Desc: Rx: seldenafil followed by placebo Grp: 3 Placebo then sildenafil age: 53(36,69) duration: 3. Sildenafil citrate (Viagra) is effective and well tolerated for treating erectile dysfunction of psychogenic or mixed aetiology. Desc: organic 1%, psychogenic 59%, mixed 40%, Rx: sildenafil 10 Lost: /1/ Discontinued: /7/ Discont. Desc: organic 1%, psychogenic 61%, mixed 38%, Rx: sildenafil 25 Lost: /1/ Discontinued: /7/ Discont. Desc: organic 0%, psychogenic 59%, mixed 41%, Rx: sildenafil 50 Lost: /0/ Discontinued: /11/ Discont. Desc: Rx: sildenafil 10 Grp: 5 Mixed etiology patients on 10mg sildenafil age: duration: Pts: 36 Pt. Desc: Rx: sildenafil 10 Grp: 6 Psychogenic patients on 25 mg sildenafil age: duration: Pts: 52 Pt. Desc: Rx: sildenafil 25 Grp: 7 Mixed etiology pts on 25 mg sildenafil age: duration: Pts: 32 Pt. Desc: Rx: sildenafil 25 Grp: 8 Psychogenic patients on 50 mg sildenafil age: duration: Pts: 48 Pt. Desc: Rx: sildenafil 50 Grp: 9 Mixed etiology patients on 50 mg sildenafil age: duration: Pts: 33 Pt. Desc: Rx: sildenafil 50 Copyright © 2005 American Urological Association Education and Research, Inc. Desc: organic 0%, psychogenic 54%, mixed 46%, Rx: Placebo 999 Lost: /4/ Discontinued: /9/ Discont.
Moreover erectile dysfunction after prostate surgery purchase super avana 160mg without prescription, as the semen coagulates at ejacu-- most erectile dysfunction and injections super avana 160 mg fast delivery, as the basic one for achieving pregnancy erectile dysfunction venous leak treatment super avana 160mg with amex. The lation the relative immotile spermatozoa are trapped answer to impotence and high blood pressure order super avana 160mg on line the critics is that ‘no evolved biological and uncapacitated so little effectual transport in to the mechanism can be effective and can ensure repro-- cervix/uterus would occur. Biological adap-- coital scenario will be that of iii), female orgasm af-- tation can serve only one particular set of conditions ter ejaculation. There is evidence, admittedly in consciously reduce the amount of semen leaking a single case, that uterine motility is inhibited after from their vagina (termed ‘lowback’) thus controlling orgasm [250] and that genital muscular relexes are the amount of semen retained which would aid fertili-- suppressed [163,205]. The effect only lasted for 1 minute before ejaculation to The female orgasm can occur at three particular time 45 minutes after. These studies and the statistics points during coitus, these are: used have been heavily criticised by Lloyd [234] who i) before ejaculation occurs, does not think that they can be relied on. Baker & Bellis [251] proposed, however, Various postulated functions for the female orgasm without any experimental measurements, that such were collected by Levin [178]. Those that could an orgasm would upsuck the acidic vaginal luid have a bearing on reproduction were a) to create making the cervical luid hostile to sperm and could lassitude in order to keep the female horizontal thus thus inluence subsequent sperm uptake. Sexual arousal per se has no smooth muscle and to inhibit urination and thus effect on the pH of cervical luid it being unchanged any subsequent sperm loss from a need to urinate from the basal values [233]. Psychological/psychiatric problems may also be a longterm complication, As described above possible pathophysiological pro-- as depression, phobia, anxiety, depression and cesses may interact on several levels of the female somatization [258] secondary to the physical and physiology and have an impact on different phases psychological trauma. The pathophysiological changes can be at many lev-- All these complications may evidently have a els: the central or the peripheral physiology of the possible affect on womens’s sexuality, though only female sexual response and may, amongst many few studies have adressed this and the reports are factors, include pathophysiological changes in cell- conlicting. Besides the sexual problems induced to-cell communication, changes in endocrine milieu, by side effects as mentioned above the damaged disruption in homeostasis of neurotransmitters and or missing structures and tissues can have a signal molecules, tissue damage, organ damage, impairing effect on sexual desire, arousal, orgasm, vascular chages and neurological changes central satisfaction and pain during intercourse. However it is important to keep in on which type of circumcision that is performed, mind that women with impaired physiology may have genital sensitivity and orgasmic response may be no sexual problems as well as women with no physi-- affected. In the study by Thabet & Thabet [259] ological changes can experience sexual problems. In the study of Elsashar [258] on gical procedures all have the potential to induce 200 circumcised women, they showed a signiicantly pathophysiological processes inluencing the sexual lower libido, arousal and satisfaction with husband function in women. They is not adressed in other chapters and a short section conclude that cultural factors in combination with is therefore added to this chapter. The most frequently cited moderator of concordance is gender, such that men show signiicantly greater concordance than women. Until now the chapter has focused on physiology and pathophysiology of women’s sexual response, but it First, agreement between actual genital arousal and is clear there is an interaction between physiology self-reported arousal in women is not zero; the aver-- and psychology in the sexual response, and recently age correlation reported by Chivers and colleagues growing evidence has shown a gender difference in was +. This of sexual response are examples of the relative suggests that women’s experience of sexual arousal independence between physiological, psychological, is not primarily related to experience of physiological and behavioral aspects of women’s sexuality. This responding and is mediated by additional cognitive section of the chapter examines current research and emotional mechanisms. It is not clear how much on concordance and nonspeciicity of women’s appraisal of subjective sexual arousal is inluenced sexual arousal within the broader context of by perception of genital responding, or vice versa, implications for psychophysiological assessment of but these measures are highly positively correlated women’s sexuality and sexual functioning, and for in women [264]. That these two self-report measures understanding the development and expression of differ in their relationship with physiologically-mea-- female sexual orientation. Sexual arousal is an of interoceptive awareness, that is, the psychological emotional state [261] and, similar to other emotions, capacity to perceive internal physiological changes. The greater reliance on The degree to which the individual’s experience of external information suggests that women’s experi-- sexual arousal corresponds with her physiological ence of sexual arousal is more inluenced by their response (concordance) is a matter of interest to re-- attitudes, beliefs, and values regarding sexuality, as searchers and practitioners in sexual medicine, since well as immediate contextual factors such as sexual 0 comitte 22. This vari-- physiological sexual response, and psychological ability in women’s concordance estimates may re-- traits, like sexual orientation, also shows marked dis-- lect the multitude of psychological factors that inlu-- cordance in women. Gender differences have been ence women’s experience of sexual arousal more so observed in the relationship between self-reported than physiological factors, suggesting a role for in-- sexual attractions (toward males or females) and pat-- dividual differences in moderating concordance be-- terns of genital and self-reported sexual arousal to tween self-reported and genital sexual arousal. This female and male sexual stimuli; men’s sexual arous-- raises fascinating questions as to the origins of con-- al patterns are very strongly associated with their cordance among women and whether concordance self-reported sexual orientation, whereas women’s is a desired state (see next section). Cognitive models suggest that concordant sexual response is a desirable, or even necessary, state Women report increased sexual arousal to both pre-- for satisfactory sexual functioning [268]. The po-- ferred and non-preferred sexual stimuli [288,290- tential for concordance to vary with sexual function-- 292], which suggests that their cognitive and affec-- ing has been demonstrated in studies of sexually tive responses to sexual stimuli are not dependent dysfunctional women; women with sexual arousal upon their sexual preferences, such as sexual orien-- problems report lower subjective sexual arousal to tation. Sexual desire, as evidenced by masturbation sexual stimuli in the laboratory, but typically do not and partnered sexual behaviors, is also kindled by show signiicantly lower genital responses when exposure to both preferred and non-preferred sexual compared to women without sexual arousal prob-- stimuli [290] suggesting that, among heterosexual lems [269,270]. Studies comparing the concordance women, motivation for engaging in sexual behavior of sexual responses of sexually functional and dys-- is also less dependent upon sexual preferences. Using may be related to better sexual functioning, such still pictures of female and male nudes, Sylva et al. While orgasm fre-- heterosexual and lesbian women’s brain responses quency, particularly during heterosexual coitus, is an showed speciicity in areas associated with process-- inadequate means of determining women’s sexual ing of visual stimuli and motivation, that is, greater function, these studies do indicate an association response to stimuli matching a woman’s sexual ori-- between concordance and orgasmic frequency that entation. Hypothalamic response, however, did not suggests concordance may be a useful index of in-- show category-speciic response for either group. Flexibility bian women only; heterosexual women showed refers to a pattern of intraindividual variability in sex-- nonspeciic amygdalar responses. With tern of results from these different lines of research respect to sexual orientation and identity, women demonstrates that speciicity and nonspeciicity of are more likely than men to experience and express peripheral sexual responses are mirrored in central same-gender attractions and less likely to engage aspects of sexual functioning in women. Therefore, a woman’s sexual desire Figure 19: Heterosexual women’s and men’s mean genital responses, in standardized z-scores (top panel), and self-reported sexual responses, in percentage increase from baseline (bottom panel), to various categories of stimuli. The stimulus category “Intercourse” in the male and female panels represents responses to depictions of two men and two women, respectively, engaged in intercourse. Self-report data on the de-- velopment of female sexual orientation support this Gender differences exist in the relationships among proposition; women report that social and emotional psychological, behavioral, and psychophysiological factors are more salient than sexual arousal to the aspects of sexuality, with greater lexibility observed development of their sexual interests in either the in women. Low concordance between genital and same gender [305, 306] or opposite gender [309]. Nonetheless, there is some patterns of sexual arousal do not constrain women’s evidence that higher concordance may be associ-- sexual behavior, feelings, or identity. The potential for discordance The potency of stimuli depicting any sexual activity between physiological sexual response, psycho-- to evoke genital response, regardless of the actors logical states of sexual arousal, and psychological portrayed or context of the sexual activity [288] traits, such as sexual orientation, strongly suggests (figure 19) is also highlighted in studies where that objective measures of sexual response should women show physiological sexual responses to not be used in isolation to draw conclusions about other clearly nonpreferred sexual stimuli, such as women’s sexuality. Genital response precedes subjective between physiological and psychological sexual arousal [316], is evident within seconds of aspects of sexual response the onset of a sexual stimulus [317], and can occur in the absence of subjective experience of sexual • Gender difference in speciicity of sexual arousal [287]. Reports of women’s genital lexibility in women’s sexual attractions response and orgasm during sexual assault [182] and research showing that women experience genital • Female genital response is a relexive responses to sexual threat stimuli suggests that response to exposure to any sexual stimulus genital response under conditions of nonpreferred depicting sexual activity, whether preferred sexual stimuli may be typical in women. For this or not reason, inferences regarding a woman’s sexual • Nonspeciic genital vasocongestion suggests desire and relative sexual attractions based solely that genital response is not a valid indicator on her genital responding would very likely be of sexual desire or sexual orientation inaccurate. Multi-subject studies will show which sites have high reproducibility and • Integration of central and are likely to be connected to the (sexual) peripheral mechanisms task, thus enhancing the power of the study. However, there are many limitations and potential • Validate the effectiveness of the chosen pitfalls that one should be aware of when planning stimuli (and the paradigm) outside the a study using these tools or even when reading a scanner in a separate group of subjects. Sexual consummation • Know your signal characteristics • Decide the type of genital stimulation to comitte 22. Requires Linux or Linux level of sexual arousal that may be used virtual machine (Vmware). Helen o’Connell, Prof Norm and rotational head motion can be easily Eizenberg and Anatomedia for the permission to measured and can be used to remove use their anatomical pictures. Helen O’Connell for her comments to correction software should be used to align the chapter. The evolution of human reproduction: a pri-- matological perspective Am J Phys Anthropol 2007;Suppl were nevertheless important during the 45:59-84. Mol Reprod Dev 1994 octo-- each other (network) rather than with the ber;39(2):184-93. Cellular and molecular mechanisms of female reproductive Analysis software behaviors. J Sex Med 2008 nisms mediating oestradiol modulation of the developing July;5(7):1559-71. Sexual differentiation of pheromone pro-- human brain activity during primary sensory stimulation. Sexual differences in visual attention to sexually explicit videos: a Differentiation of the Brain. Sex-speciic content preferences for vi-- diol mediates developmental masculinization of sex be-- sualsexualstimuli. Female sexual hancing glutamate release: a mechanism for organiza-- arousal: a behavioral analysis. Neuroanatomical correlates of visually evoked sexual [20] Pfaus J, Giuliano F, Gelez H.
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