The Sexuality Project (Pro-Sex) of the Institute of Psychiatry of the HCFMUSP: first year of activities

The results of one year of activities of a multidisciplinary staff comprised of five psychiatrists, one urologist, one gynecologist, and seven psychologists, who integrate the Sexuality Project (PRO-SEX) of the Institute of Psychiatric, Hospital das Clfnicas, College of Medicine, University of Sao Paulo (FMUSP), are presented, Different sexual disorders were evaluated and treated in 140 patients (116 men and 24 women). In addition, a standard protocol was established for the medical assistance of patients; four research projects have been initiated; and courses were offered to residents in psychiatry, urology, and obstetrics-gynecology, as well as to undergraduate and postgraduate students of FMUSP.The PRO-SEX staff presented their research at one congress and two symposiums, and published four articles. Furthermore, an extensive program was established for 1995 in order to continue the advanced medical study of human sexuality.


T he
Sexuality Project (PRO-SEX) is a multidisciplinary project developed to establish priorities in the treatment of sexual disorders, and attend to the needs for assistance, education and research in this area.This approach was proposed because human sexuality and its disorders, cannot be properly studied within a single medical specialty.
The staff of PRO-SEX is comprised of psy~hiatrists, psychotherapists (physicians and psychologists), urologists, gynecologists and administrative assistants.It began its activities in November 1993.
From November 1993 through November 1994, 176 patients, 142 men and 34 women, were admitted to our service.Medical assistance was initiated by a performing psychiatric examination, followed by an urological or gynecological examination, according to the sex of patient.Patients were only treated if a sexuality disorder was diagnosed according to the International Classification of Diseases, 10 th edition.I Patients received clinical support (psychiatric, urological, and gynecological) if sexual disorders were due to organic causes.B~'ief psychotherapy, individual or in group, was used whenever disorders were psychogenically associated or not associated to organic disturbances.Figures I and 2 illustrate some characteristics of patients admitted to this study.
On a weekly basis, the medical staff sponsored meetings to present research projects in progress and seminars on impOltant issues; to discuss clinical cases; to establish plans for expanding educational, scientific and assistance activities; and to review the main objectives of this project.

HISTORY
The nursing and medical staff of the Institute of Psychiatry (IPQ) of the Hospital das Clfnicas (HC), College of Medicine, University of Sao Paulo in the last few years has had an increasing demand for assistance by patients whose main or minor complaints were related to sexual disorders.
Simultaneously, other specialties of the HC complex have been subject to similar demands, especially the disciplines of urology, gynecology and obstetrics.These patients were sent to IPQ for expert consultation or clinical evaluation.Their sexual complaints included: premature ejaculation, erectile dysfunction, anorgasmy, or dyspareunia.
This system did not allow an adequate interdisciplinary follow-up.The waiting period for patient admittence to IPQ became progressively longer.
In addition, the absence of a systematic protocol did not permit a standardization of procedures to be adopted and scientifically evaluated.In fact, a standard procedure is necessary to establish treatment for different groups of patients, and to validate different treatments or to indicate new directions.
Faced with this situation and aware of the complexity of this issue and its implications on other spheres of human existence, the Sexuality Project was organized in a multidisciplinary manner.

ACTIVITIES
Assistance, education and research are the main objectives of the Sexuality Project (PRO-SEX), which has been developed according to the following premises:

Assistance
Initially, patients of both sexes are submitted to triage and examined by a psychiatrist; men are then evaluated by a urologist and women by a gynecologist.
Once patients are admitted to PRO-SEX, they are submitted to a psychiatric evaluation and to the following specific anamnesis: Sexual identity: (approval or disapproval of their biological sex).

MASCULINE SEXUALITY
Sexual orientation: the opposite sex, the same sex, objects, masturbation (type).
Importance of sexual activity (in the beginning, currently).
Sexual intercourse: performance during lifetime (in the beginning, evolution and current status) Frequency of sexual intercourse and favorite caresses Use of stimulating drugs to facilitate performance.Emotional life related to sex: need for an emotional relationship, and its interference in sexual pleasure.
Current status of the emotional-sexual life: the presence or absence of a steady partner; number of partners; frequency of sexual intercourse; incidents during sexual intercourse (reported spontaneously or prompted).
Importance of values: (cultural, religious, family, related to children, related to the masculine role) and their interference on sexual performance and sexuality.

FEMININE SEXUALITY
Upbringing: education, perception and/or experience of sexuality at home, with friends or relatives.
Menarche, nlenopause and pregnancies: number of pregnancies and their acceptance.
Abortions: spontaneous, or induced.Sexual initiation: masturbation, childhood sexual play, first relationships, first experiences (fantasies, frequency and preferences).
Sexual identity: (approval or disapproval of the biological sex).
Sexual orientation: the opposite sex, the same sex, objects, masturbation (types).
Importance of sexual activity: (in the beginning, currently).
Sexual intercourse performance: throughout life (in the beginning, evolution and current status); incidents: pain, bleeding, etc; Frequency: of sexual intercourse and favorite caresses Emotional life related to sex: need for a relationship, and its interference in sexual pleasure.
Use of stimulating drugs: to facilitate performance.Current status of the emotional-sexual life: Presence or absence of a steady partner; number of partners; frequency of sexual intercourse; incidents during sexual intercourse (reported spontaneously or prompted).
Importance of values: (cultural, religious, family, related to children, related to feminine behavior) and their interference on sexual performance and sexuality.
Once patients are thus evaluated and properly diagnosed, they receive specific treatment, i.e., clinical (psychiatric and/or urological or gynecological) or psychodynamic, or both.
Clinical treatment of the underlying mental disorder is based on psychiatric assistance (if the primary disturbance is prior to the sexual disorder).If necessary, psychotherapy is used for a brief period, and focuses on the current sexual disorder.Groups of "Ii mited thematic therapy" are organized -i.e., groups which will approach a specific subject based on patient diagnosis (e.g .. premature ejaculation) -for 12-16 weeks.Thus, these groups are comprised of patients with the same sexual disorder.
Individual psychotherapy, along different lines, is recommended whenever the psychic structure of the patient is such that psychotherapy in group should not be used.
The diagnosis of concomitant etiologies determines multidisciplinary assistance.

RESEARCH
PRO-SEX has developed the following research projects: "Limited thematic therapy for male patients with sexual disorders" (working title  3 Abdo CRN."A mulher no contexto s6cio-psfquico: Sexo e Dominac;ao"/"Women in a socialpsychological perspective: sex and domination" (Round Table Topic).XIII Congresso Brasileiro de Psiquiatria.Pousada do Rio Quente, Anais, 1994. 4

Postgraduation
In 1994, a comparative study of anxiety disorders and premature ejaculation was started and is currently being carried out by Sergio Ricardo Campanella de Oliveira under the supervision of Prof Dr. Carmite R.N. Aldo, for a Masters degree.

Education
In 1994, PRO-SEX was responsible for the following educational activities for:

Undergraduate students
Lecture: "Aspectos psicol6gicos do desenvolvimento da Sexualidade"/ "Psychological aspects of sexual development" for the Course of Medical Psychology for the third-year students ofFMUSP.Lecturer: Prof. Dr. Carmita R.N.Abdo.Lecture: "A famnia como mantenedora da doenc;a"/ "The family as a maintainer of disease" for the Course of Medical Psychology for third-year students of FMUSP.Lecturer: Prof. Dr. Carmita R.N.Abdo.

INTERNSHIPS
For physicians: Dr. Celso Gromatzky, urologist, and Dr. Joserita Serrano de Assis, gynecologist, are responsible for the clinical assistance of patients in the PRO-SEX.They take part in weekly clinical meetings, and participate in research of a multidisciplinary approach.For psychologists: Andrea Newmann, Alina D.D. Barone, Aurea R. Giaquinto, Beatriz Kalman, Cecflia Brasiliense Carneiro, Ymara L.C. Victolo, Marco Antonio P. Amato, Rita Di Giacomo Domingues collaborate in psychotherapeutic assistance, and take part in clinical meetings and research projects.

DEMOGRAPHIC DATA AND DIAGNOSES OF PATIENTS ADMITTED TO PRO-SEX, DURING THE FIRST YEAR OF ACTIVITIES
The patients assisted by the clinical staff of PRO-SEX were evaluated in open interviews by psychiatrists, gynecologists, and urologists.The patients suspected of primary sexual disorders were examined by a urologist (male patients) or a gynecologist (female patients) to exclude the possibility of pathologies of this type.
The psychiatric diagnosis for each patient was recorded in their medical files, and standardized according to the International Classification of Diseases, 10th edition, ICD 10 (1993).Demographic data were obtained by consulting IPQ files.

GENDER
One hundred forty patients were selected from a total of 176 cases assisted during the period of this study: 116 were male (82.9 percent), and 24 were female (17.1 percent), as depicted in Figure 1.

AGE
Patients were categorized into three distinct groups based on age, regardless of sex: 18 to 35, 36 to 60, and older than 60 years.The men's ages ranged from 18 to 76 years, and the women's from 19 to 67.The distribution of patients according to age is shown in Figure 2a and 2b.
The mean age of men (37.8 years) is higher than of women (35.2 years).Most of the patients were between 18 and 35 years (47.4 percent male and 58.3 percent female).The younger groups sought medical assistance more often (18 to 35, and 36 to 60 years), corresponding to 92.2 percent of male and 91.6 percent of female cases.

ORIGIN
All patients admitted came from the city of Sao Paulo.

CIVIL STA TUS
As shown in Table I, most of the female patients were married (54.2 percent); single women accounted for 37.4 percent of the cases.On the other hand, most of the male patients were single (46.6 percent), and married men accounted for 42.2 percent.

GENERAL CONSIDERA TIONS
As shown in Table 2, from a total of 140 patients with 4.3 percent (6 cases) not being properly classified, 2.9 percent (4 male cases) had a sexual disorder of organic origin.
One hundred thi rty patien ts had psych iatric diagnoses (92.9 percent of total cases): 107 were male (82.3 percent) and 23 were female (17.7 percent).For comparing data, analyses of different diagnoses were performed for each sex.This survey also revealed that 32 patients (24.6 percent) showed more than one psychiatric diagnosis; mainly erectile dysfunction and premature ejaculation in 10 cases (31.3 percent of the diagnostic associations and 7.7 percent of total diagnoses).
Other associations will be shown separately for masculine and feminine disorders.
Three patients (two men and one woman) (2.3 percent of the total cases) were homosexual.However, only the female case could be classified by the adopted diagnostic criterion, due to the ego-dystonic character of her sexual orientation (F66.1).

DIAGNOSTIC DATA FOR MALE PATIENTS
According to the data shown in Table 3, the most frequent diagnosis is premature ejaculation (47 cases, 36.7 percent of total cases and 43.9 percent of male cases), followed by erectile dysfunction (44 cases, 34.0 percent of total cases and 41.1 percent of male cases).These two disorders account for 85.0 percent of diagnoses in male patients.

Diagnosis
The most frequent psychic disorders associated with male sexual dysfunction are: personality disorders (3 cases, 2.8 percent male cases); episodes of depression (2 cases, 1.9 percent male cases) and episodes of anxiety (5 cases, 4.7 percent male cases).
Two cases (1.9 percent male patients) of transsexual ism, 3 cases (2.8 percent) of sexual preference disorders (the well-known paraphilia), and two cases (1.9 percent) of psychological disorder and abnormal behavior associated with sexual development and orientation (F66) were also observed.
Thus, most male patients (86.7 percent) presented diagnoses of the group F50-F59 (Behavioral syndromes associated with physiological disturbances and physical factors), and only 7.4 percent cases presented diagnoses ofthe group F60-F69 personality (Personality and behavior disorders in adults).The others (5.6 percent) did not present any sexual disorder.

DIAGNOSTIC DATA FOR FEMALE PATIENTS
In regard to the female sex, according to Table 4, the most frequent disorder was orgasmic dysfunction (73.9 percent female patients); two cases (8.7 percent) of anorgasmy, 2 cases (8.7 percent) of dyspareunia, I case (4.3 percent) of vaginismus, and I case (4.3 percent) of ego-dystonic homosexuality were also observed.There was also one case (4.3 percent) of orgasmic dysfunction associated with dyspareunia, and I case that could not be classified as a sexual disorder (F60.9 -nonspecified personality disorders).Among all female patients, 4 cases (17.4 percent) presented a psychiatric diagnosis associated with an identified sexual disorder, and all of these patients presented anxiety disorders (3 cases of generalized anxiety disorder, and I case of nonspecified anxiety).
No cases of paraphilia were observed, confirming the results of literature about their absolute predominance in men.
Most of the female patients (95.6 percent) were classified in the group F50-F59, and only 4.4 percent in the group F60-F69.Similarly to the male population, these findings demonstrate the prevalence of sexual dysfunctions associated with sexuality disorders.

EXPANSION OF PRO-SEX IN 1995
The I st Symposium on Sexuality, "Diagnosis and treatment of sexual disorders," is in its final stage of organization, and will be directed at professionals in the mental health area.This event will be held at the Institute of Psychiatry of HCFMUSP in October 1995.
The Educational Clinic of Sexual Disorders, was started in February 1995, and is held weekly, mainly for second-year psychiatry residents of the Institute of Psychiatry of HCFMUSP.
The following are in the planning and organizational stage: the Clinic of Sexuality in Pregnancy (to be established with the Obstetrics Course of the HCFMUSP); the Clinic of Sexuality in Menopause (with the Gynecology Course of the HCFMUSP); and the Clinic of Sexuality in physically-rehabilitated persons (with the Rehabilitation Hospital of HCFMUSP).
Two new projects will be initiated by PRO-SEX for Master's degrees in 1995: "Female orgasmic dysfunction: normal variation of sexuality, autonomous nosological symptom or entity," by Fabio Schimidt Goffi Jr. "Limited group psychotherapy for treatment of erectile dysfunction," by Filipe Jorge Dontel Teixeira Soares Ferreira.The Sexuality Project will be restructured in 1995, and will have three areas: assistance, education and research.Thus, PRO-SEX intends to take a new step in the advanced study of human sexuality, from a clinical" point of view.

Figure 2a -
Figure 2a -Proportion of Male Patients Admitted to Pro-Sex, According to Age And Age Group (Nov.93/ Nov. 94).

Figure 2b -
Figure 2b -Proportion of Female Patients Admitted to Pro-Sex, According to Age And Age Group (Nov.93/ Nov. 94).

'
Sexual Preference Psych.Behav.Dis.Assoc.Sex.Dev.Orient***No Associated Sexual Diagnoses "Secondary Diagnosis of Sexual Dysfunction "'Specific Diagnosis Only for the Group •••• Psychic Disorder And Abnormal Behavior Associated with Sexual Development and Orientation # Some Patients Presented more than One Psychiatric Diagnosis OLIVEIRA, S.R.C. & ABDO, C.H.N. -The Sexuality Project (PRO-SEX) of the Institute of Psychiatry of the HCFMUSP: First year of activities Sao Paulo Medical Journal/RPM 114(4): 1208-1215, 1996

TABLE 1
Distribution of Patients Admitted to PRO-SEX, According to Civil Status (Nov.93/ Nov. 94)

TABLE 4
Frequency of Diagnoses Among Female Patients