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PS9.1-2 | Psychosexual Health — Practice Quiz
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A 34-year-old married man presents with inability to achieve penile erection sufficient for intercourse over the past 8 months. He reports normal morning erections and is able to achieve erection during masturbation. His physical examination, fasting glucose, and testosterone levels are within normal limits. Which phase of the sexual response cycle is primarily affected?
Correct. Erectile dysfunction (ED) is a disorder of the arousal phase of the sexual response cycle. Preservation of nocturnal/morning erections and masturbatory erections in the absence of organic pathology strongly points to psychogenic ED, where performance anxiety triggers sympathetic activation that impairs the parasympathetically mediated vasodilatory response needed for erection.
Erectile dysfunction is an arousal-phase disorder. Situational pattern (intact alone, failed with partner) is the hallmark of psychogenic causation.
Erectile dysfunction is classified under disorders of the arousal phase. In Kaplan's triphasic model (desire → arousal → orgasm), arousal encompasses genital vasocongestion and lubrication. The pattern described — intact morning erections but situational failure with a partner — is classic for psychogenic etiology within the arousal phase.
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A 28-year-old woman presents with recurrent involuntary contraction of the vaginal musculature that prevents penile penetration. She reports normal sexual desire and is able to achieve orgasm through non-penetrative stimulation. Her gynaecological examination is unremarkable. Which is the most likely diagnosis?
Correct. Vaginismus (classified in ICD-11 under genito-pelvic pain/penetration disorder) is characterised by involuntary contraction of the pelvic floor muscles that prevents vaginal penetration. Preserved desire and non-penetrative orgasm rule out desire and orgasmic disorders. Dyspareunia involves pain during intercourse but does not feature the involuntary spasm that prevents penetration.
Vaginismus = involuntary vaginal muscle spasm preventing penetration. Preserved desire and non-penetrative orgasm help distinguish it from other female sexual dysfunctions.
The key features here are involuntary muscular contraction preventing penetration, intact desire, and intact orgasmic capacity through alternative stimulation. This triad is diagnostic of vaginismus (ICD-11: genito-pelvic pain/penetration disorder). Dyspareunia is pain during intercourse; vaginismus is prevention of penetration by spasm.
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According to ICD-11, the sexual dysfunctions are classified primarily in which chapter?
Correct. ICD-11 made a significant and deliberate reclassification: sexual dysfunctions and gender incongruence were moved out of Chapter 6 (mental disorders) and placed in Chapter 17 — Conditions Related to Sexual Health. This reflects the understanding that sexual dysfunctions are primarily health conditions affecting sexual wellbeing, not mental disorders per se.
ICD-11 reclassified sexual dysfunctions from mental disorders to Chapter 17 (Conditions Related to Sexual Health). This reduces stigma and reflects current understanding of sexual health.
ICD-11 deliberately moved sexual dysfunctions from the mental disorders chapter (Chapter 6) to Chapter 17 — Conditions Related to Sexual Health. This is a clinically and ethically important change that reduces stigma and recognises sexual health as a distinct health domain.
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A 32-year-old man presents with ejaculation occurring consistently within 60 seconds of vaginal penetration, causing significant personal distress. This has been present since his first sexual experience. The most appropriate first-line psychological intervention is:
Correct. Premature ejaculation (PE) responds well to behavioural sex therapy techniques. The stop-start technique (Semans) involves ceasing stimulation at the point of ejaculatory inevitability until arousal subsides, then resuming. The squeeze technique (Masters and Johnson) applies pressure to the glans at the same point. Both train ejaculatory control. These are established first-line psychological interventions for PE.
Premature ejaculation: first-line behavioural = stop-start (Semans) and squeeze (Masters & Johnson) techniques. Pharmacological adjunct: SSRIs (dapoxetine, off-label paroxetine/sertraline).
For premature ejaculation, the primary behavioural interventions are the stop-start technique (Semans) and the squeeze technique (Masters and Johnson). Systematic desensitisation is used for anxiety-based avoidance disorders. Sensate focus is used for broader sexual anxiety and desire/arousal problems. Cognitive restructuring alone is insufficient for an ejaculatory control problem.
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Which of the following correctly distinguishes organic from psychogenic erectile dysfunction?
Correct. The presence of nocturnal penile tumescence (NPT) — assessed by the stamp test or formal NPT monitoring — is a key differentiator. Psychogenic ED preserves the physiological erectile mechanism (parasympathetic vasodilation remains intact), so nocturnal erections occur normally. Organic ED (vascular, neurogenic, endocrine) impairs the mechanism itself, so NPT is absent or reduced. Organic ED typically has gradual onset; psychogenic ED may be acute and situational.
Preserved NPT = psychogenic ED (intact mechanism, psychological inhibition). Absent/reduced NPT = organic ED (mechanism impaired).
The key differentiator is nocturnal penile tumescence. In psychogenic ED, the physiological mechanism is intact — only contextual/psychological triggers impair it — so NPT is preserved. In organic ED, the vascular, neurogenic, or endocrine mechanism is impaired, abolishing NPT. Organic ED typically has gradual onset; psychogenic can be acute.
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In the Supreme Court of India judgment in NALSA v. Union of India (2014), the Court held that:
Correct. NALSA v. Union of India (2014) was the landmark Supreme Court judgment that recognised transgender persons as a third gender under the Indian Constitution. The Court held that the right to self-identify gender is a fundamental right protected under Articles 14 (equality) and 21 (personal liberty and dignity). The decriminalisation of consensual same-sex acts occurred separately in Navtej Singh Johar v. Union of India (2018).
NALSA 2014 = transgender third-gender recognition + right to self-identify gender (Articles 14 & 21). Navtej Johar 2018 = decriminalisation of consensual adult same-sex acts (read down Section 377 IPC).
NALSA v. Union of India (2014) specifically addressed transgender rights — recognition as a third gender and the constitutional right to self-identify gender. The decriminalisation of consensual adult same-sex intercourse was the holding of Navtej Singh Johar v. Union of India (2018), which read down Section 377 IPC. These are two distinct landmark judgments that every psychiatrist must know.
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According to ICD-11, which of the following statements about homosexuality and gender incongruence is accurate?
Correct. ICD-11 (adopted 2022) made two critical changes: (1) Homosexuality and ego-dystonic sexual orientation are no longer classified as mental disorders at all — they were removed entirely. (2) Gender incongruence was moved from the mental disorders chapter (Chapter 6) to Chapter 17 (Conditions Related to Sexual Health). These changes reflect scientific consensus that sexual orientation and gender identity are normal variants of human diversity, not pathological conditions. Being transgender is a health condition warranting support, not a mental disorder.
ICD-11: Homosexuality = not a disorder (no classification). Gender incongruence = Chapter 17 (sexual health), NOT mental disorders. Ego-dystonic sexual orientation was abolished entirely.
ICD-11 removed all orientation-based diagnoses (including ego-dystonic sexual orientation) from the classification. Gender incongruence is in Chapter 17 (Conditions Related to Sexual Health), not Chapter 6 (mental disorders). ICD-10's ego-dystonic sexual orientation was abolished entirely in ICD-11 — distress about one's orientation may warrant support, but the orientation itself is not a disorder.
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A 22-year-old transgender woman presents with depression and anxiety. During history-taking, the resident doctor repeatedly refers to her using male pronouns despite being corrected twice. Under the Mental Healthcare Act, 2017 (MHCA 2017), this behaviour is:
Correct. MHCA 2017 Section 18 guarantees every person with a mental illness the right to non-discriminatory treatment with dignity, including protection against cruel, inhuman, or degrading treatment. Persistent misgendering after being corrected violates the patient's dignity, worsens therapeutic alliance, and increases the minority-stress burden known to exacerbate depression and anxiety. NALSA 2014 also affirms the right to self-identify gender. A psychiatrist must use the patient's identified pronouns and name as a basic standard of affirmative care.
MHCA 2017: non-discrimination + dignity are statutory rights. Misgendering after correction = dignity violation. Use the patient's identified pronouns and name — always, regardless of documents.
MHCA 2017 contains explicit non-discrimination and dignity provisions that apply here. Persistent misgendering after correction is not a minor procedural matter — it is a dignity violation with direct clinical consequences (worsened therapeutic alliance, increased minority stress, exacerbated depression). It is not permissible under any rationale, including document discrepancies.
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A psychiatry colleague suggests referring a gay patient for 'conversion therapy' to change his sexual orientation. As his treating psychiatrist, your most appropriate response based on current professional and ethical standards is:
Correct. Conversion therapy (also called reparative therapy) is condemned by the World Health Organization (WHO), the World Psychiatric Association (WPA), the Indian Psychiatric Society (IPS), and all major professional psychiatric bodies as: (1) ethically impermissible — it pathologises a non-disorder; (2) ineffective — no credible evidence of orientation change exists; (3) harmful — associated with depression, suicidality, anxiety, and PTSD. Sexual orientation is not a mental disorder in ICD-11. A patient's distress about their orientation should be addressed through affirmative therapy that explores minority stress, internalised homophobia, and societal pressures — not through attempts to change the orientation.
Conversion therapy: condemned by WHO, WPA, IPS — harmful, ineffective, unethical. Sexual orientation is not a disorder. Distress → affirmative therapy targeting minority stress, not orientation change.
Conversion therapy is unconditionally condemned — it is never appropriate regardless of patient request, duration of distress, or functional impact. ICD-11 does not classify homosexuality as a disorder. Affirmative therapy addresses the distress (minority stress, internalised homophobia, social pressures) while supporting the patient's identity. Pharmacological libido suppression is also ethically impermissible for this purpose.
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Hypoactive sexual desire disorder (HSDD) in women, as classified in ICD-11, primarily involves:
Correct. Hypoactive sexual desire disorder (HSDD) is defined by persistently deficient or absent sexual fantasies/thoughts and desire for sexual activity, causing clinically significant personal distress or interpersonal difficulty. It is a desire-phase disorder. The diagnosis requires that the deficiency is not better explained by a relationship problem, a medical condition, substance use, or another mental disorder.
HSDD = desire phase. Hallmark: deficient/absent sexual fantasies and desire causing personal distress. Distinguish from arousal (lubrication), orgasm, and pain disorders by careful phase-based history.
HSDD is specifically a disorder of the desire phase — absent or markedly reduced sexual interest and fantasy. Inability to achieve lubrication is a female genital arousal disorder (arousal phase). Pain during intercourse is dyspareunia (sexual pain disorder). Absent orgasm is female orgasmic disorder (orgasm phase).
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