The sexual health of people due to their high personal significance is no less important than their physical health. WHO experts in 1977 proposed the following definition: “Sexual health is a complex of somatic, emotional, intellectual and social aspects of a person’s sexual existence, which positively enrich a person, increase a person’s sociability and ability to love”. The concept of sexual health includes three basic elements: 1) the ability to enjoy and control sexual and childbearing behavior in accordance with the norms of social and personal ethics; 2) freedom from fear, feelings of guilt, misconceptions and other psychological factors that suppress sexual reactions and interfere with sexual relationships; 3) the absence of organic disorders, diseases and disorders that interfere with the implementation of sexual and childbearing functions.
The famous Ukrainian sexologist, Professor V. V. Krishtal (1997) believes that the sexual health of a person is ensured by four factors – social, psychological, socio-psychological and biological. Its social security is determined by the attitude of society towards sex, the level of sexual culture, people’s mastery of sexual and social norms, the development of adequate sexual needs, etc. The psychological support for sexual health is determined by the role of individual psychological characteristics of the person, conscious and unconscious mental processes in the development of sexuality and its specific manifestations.
Socio – psychological support of sexual health is due to the paired nature of the sexual function, the formation of a small social group (family or partner couple), the prevailing ideas in society about the difference between male and female social roles and stereotypes of masculinity and femininity. The biological provision of sexuality is determined by genetic factors, the correct anatomical structure and the normal functioning of the organs and systems of the human body. Since sexual health has multidimensional support and is determined by a whole complex of interacting components, a systematic approach, which is traditionally used by domestic sexologists in practical work, is needed to assess its state and correct possible disorders.
Epidemiological studies in the field of sexopathology face certain difficulties. Information obtained both from direct examination of patients and from various medical institutions is not reliable enough. This is due to the fact that, firstly, patients often hide their sexual dysfunction, secondly, the data obtained depend on the clinical qualifications and orientation of the researcher, thirdly, there are serious discrepancies in diagnostics among sexopathologists belonging to different schools, as well as significant differences in research methods. (V. V. Krishtal, B. L. Gulman, 1997). The prevalence of sexual problems in people of both sexes can be judged, for example, from one of the most representative studies of sexual behavior in the United States, conducted as part of the Health and Social Life Review Program (HNSLS). During the survey, it was found that a decrease or lack of interest in sexual activity is observed in 16% of men, insufficient erection was detected in 19%, and 29% of the surveyed indicated a too rapid onset of ejaculation and orgasm. In turn, 34% of women reported no interest in sex, 19% had insufficient vaginal hydration during sexual intercourse, almost 25% of women indicated inability to reach orgasm with a partner, 15% of women worried about pain during coitus (E. Laumann , J. Garnon, R. Michel, S. Michaels, 1994).
There is evidence that more than 10 million men in the United States suffer from erectile dysfunction, from 3 to 5 million men in Germany and about 6 million men in Russia. Premature ejaculation occurs in almost 10% of young people. According to some estimates, between 15 and 40% of men suffer from various forms of sexual dysfunction (permanently or periodically). Sexual coldness and problems with orgasm occur in about 11-30% of women. In the course of a program to study the aging of men in Massachusetts (MMAS), 1,709 men aged 40 to 70 years were subjected to a multidisciplinary survey. Of the total number of 1290 people surveyed, they fully answered all questions concerning their sexual life. The following data on the prevalence of erectile dysfunction in middle and old age were obtained: minimal erectile dysfunction – 17%; moderate violations – 25% and total impotence – 10%. (H. Feldman, D. Holdstein, 1994).
A typical fact of clinical practice is the presence in patients of several sexological complaints at the same time, and their sexual dysfunctions are most often due to the complex interweaving of various etiopathogenetic factors. A holistic approach to the study of the multi-level provision of the sexual sphere and the identification of its pathology is proposed by the system concept of the stages and components of the copulative cycle (G.S. Vasilchenko, 1977, 1990). Based on it, G.S. Vasilchenko developed a method of structural analysis of sexual disorders. Structural analysis allows to identify the pathology of each of the components of the copulative cycle, assess the nature of the existing disorders (sexopathological syndromes) and determine the correlation between them, that is, the real contribution of each of the identified syndromes to the patient’s sexual disorder (GS Vasilchenko, 1983) . This allows a differentiated approach to treatment and to focus the main therapeutic efforts on the correction of core pathology, that is, the disorders that have the greatest importance in the formation of sexual dysfunction. The systemic, interdisciplinary approach adopted by the majority of professionally oriented sexologists, and the structural analysis of sexual disorders are the methodological basis for conducting clinical research in the field of sexopathology.
From the standpoint of structural analysis, the diagnostic conclusion should reflect both the main clinical manifestations of sexual dysfunction and the levels of damage to functional systems (all nosological forms or clinical syndromes are indicated in order of importance). Additionally, parameters of the patient’s sexual constitution, his character traits, nuances of interpersonal and intimate relationships with a relevant partner, etc. can be noted. Such a diagnostic conclusion adequately reflects the clinical and pathogenetic features of the sexual disorder in a particular patient, which makes it possible to develop an adequate therapeutic strategy for him .
Currently, the transition to psychiatric systematics has been carried out in Russia and Belarus in the 10th revision of the ICD, which contains diagnostic headings for sexual disorders.
The principles for identifying the main diagnostic categories of sexual disorders in ICD-10 differ significantly from those in the system-syndromological approach. Their qualifications are based primarily on phenomenological signs and less take into account etiopathogenetic factors. The classification of sexual dysfunctions of psychogenic etiology, set out in the headings F52.0 – F52.9, is based on ideas about the connection of sexual disorders with a certain phase of the human sexual cycle. There are 4 such phases, following each other: 1) attraction (desire); 2) arousal; 3) orgasm; 4) resolution, each of which corresponds to certain sexual dysfunctions (H. S. Kaplan, B. J. Sadock, 1994; G. Kelly, 2000). From the point of view of the developers of ICD-10, it may be possible to identify the undoubted psychogenic or organic etiology of sexual dysfunctions. But more often, determining the relative values of psychological and / or organic factors is difficult. Therefore, it is recommended to treat such conditions as mixed or uncertain etiology.
B.L. Vinokurov (1991) believes that virtually all sexual dysfunctions described in section P52 are related to mental disorders according to G.S. Vasilchenko, and their main method of treatment is psychotherapy. It is noted that in contrast to the pathogenetic classification of G.S. Vasilchenko, relying on the multidisciplinary concept of sexopathology, ICD-10 contains an attempt to isolate psychosexual disorders in isolation, with a special focus on their inorganic genesis. From the standpoint of modern sexology, such an attempt can hardly be considered valid, although it is inevitable in the light of the desire to preserve sexual pathology in the chapter on mental disorders. Therefore, it can be considered with some reservations that ICD-10 covers only a part of sexual disorders, namely, those that are attributed to mental component disorders in domestic sexopathology. The main requirement contained in virtually every taxon is the mandatory exclusion of the organic nature of these disorders. However, this is often a difficult task, since almost all of these disorders are systemic in nature when psychogenic factors are closely intertwined with organic ones, which takes into account the pathogenetic classification (AA Tkachenko, GE E. Vvedensky, NV Dvoryanchikov, 1998 ). In the classification of these disorders are increasingly referred to the state of mixed or organic Genesis. So, already in DSM III R there were terminological changes, psychosexual dysfunctions were called simply sexual, which was explained by the possibility of their complex genesis – psychogenic and biological at the same time. An even more radical change in approaches was embodied in DSM-IV, where new systematics units were added — secondary sexual dysfunctions caused by the use of alcohol, drugs and other toxic substances, as well as “non-psychiatric medical conditions”, that is, various somatic diseases. This was the result of the decision to expand the former section of organic mental disorders and to arrange “secondary along the third axis” disorders in their own phenomenological groups. ICD-10 did not follow these changes, still talking about “sexual dysfunction, not associated with organic disorders or diseases …”. Anyway, terminological changes, which are behind the conceptual update attempts, occur with the introduction of each of the following classification (AA Tkachenko, 1999). So, the division of sexual disorders into organic and inorganic (psychogenic) is sufficiently conditional and, given the close intertwining of constitutional premorbid (biological) prerequisites, possible somato-neurological disorders, negative psychological factors and neurotic mechanisms involved in the development of sexual dysfunctions in men, in most cases can only be carried out on the core (leading) pathology of the systems providing copulative cycle. In such a situation, the allocation of mixed sexual dysfunctions in ICD-10 is fully justified; however, due to its polysyndromism and polyetiology, a very large proportion of sexual disorders can be attributed to them.
Moreover, such a diagnosis does not give a clear idea of the structure of the sexual disorder and its pathogenetic mechanisms. Therefore, when using ICD-10, it seems appropriate to consider sexual dysfunctions, in the development of which psychogenic factors are of predominant importance, under diagnostic headings F52.0 – F52.9, and disorders of predominantly organic genesis – in the relevant sections of the classification. So, vasculogenic erection dysfunctions belong to the rubric N48.4 (impotence of organic origin). An additional code may be used to identify the cause of the erection disorder, as recommended by ICD-10. For example, in cases of atherosclerotic lesions of the arteries supplying the genitals I 70.8 (atherosclerosis of other arteries), with pathological venous outflow from the cavernous bodies I 87.8 (other specified lesions of the veins). Secondary neurotic disorders that complicate a sexual disorder of vasculogenic or other organic etiology may be further reflected in the diagnosis, and in these cases, sexual dysfunction actually has a mixed etiology.
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