Sexual Disorders

Main areas of classification

„ Sexual Dysfunctions „ Sexual Disorders „ Gender Identity Disorder

Sex, the culture, & research

„ Sex and zeitgeist „ Ideas of what are normal and abnormal are constantly changing „ e.g., masturbation

„ used to be seen as a mental disorder

„ now it's not, even within marriage it's OK

1 Sex, the culture, & research

„ Kinsey survey around sexual behavior „ 1948-1953 „ interviewed 20,000 people „ created controversy: „ number of people who are homosexual

„ Kinsey: 10%

„ others say 1%

„ probably between these figures, but we don't know for sure yet

Sex, the culture, & research

„ Masters & Johnson „ brought study of sexual behavior into the laboratory „ tried to learn about the physiology of the sexual response „ described phases of the response

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Sexual Dysfunctions

„ Sexual Dysfunctions Involve Desire, Arousal, and/or Orgasm „ Males and Females Experience Parallel Versions of Most Dysfunctions „ 43% of all females „ 31% of males „ Most prevalent class of disorder in the United States

Sexual Dysfunctions

„ Most persons suffer from more than one dysfunction „ Classification of Sexual Dysfunctions „ Lifelong vs. acquired „ Generalized vs. specific „ Due to psychological factors alone or in combination with a medical condition

3 Sexual Desire Disorders

„ Hypoactive Sexual Desire Disorder „ Little or no interest in any type of sexual activity „ Masturbation, sexual fantasies, and intercourse are rare in this disorder „ Accounts for half of all complaints at sexuality clinics „ Prevalence rates

„ 33% women

„ 16% men

Sexual Desire Disorders

„ Sexual Aversion Disorder „ Little interest in sex „ Extreme fear, panic, or disgust related to physical or sexual contact „ 10% of males report panic attacks during attempted sexual activity

Sexual Arousal Disorders

„ Male Erectile Disorder „ Difficulty obtaining and maintaining an erection „ very humiliating to many men „ vicious cycle - man gets afraid that it's going to happen again, then he starts worrying, and this prevents him from getting one again „ men don't realize is that the length of time it takes to get an erection changes Two types: „ primary - never had an erection before - this is pretty unusual „ secondary - used to be able to have them, has now lost the ability to get them

4 Sexual Arousal Disorders

„ Female Sexual Arousal Disorder „ Difficulty achieving and maintaining adequate lubrication „ Arousal disorders issues for both genders „ Must look at health problems „ diabetes, blood pressure problems, medications for blood pressure, kidney problems (antidep) „ must rule these out „ Then look at psychological factors (history) „ traumatic experience „ relationship problems „ alcohol and drug issues

Sexual Arousal Disorders

„ Associated Features of Sexual Arousal Disorders „ Problem is arousal, not desire „ Prevalence rates „ 5% of males „ 14% of females „ Males report being more troubled by the problem than females „ Erectile problems are the main reason males seek help

Orgasm Disorders

„ Inhibited Orgasm: Female and Male Orgasmic Disorder „ Inability to achieve orgasm despite adequate sexual desire and arousal „ Rare condition in adult males, but is the most common complaint of adult females „ Prevalence „ 25% of adult females report significant difficulty reaching orgasm „ 50% of adult females report experiencing regular orgasms during intercourse

5 Orgasm Disorders

„ Premature Ejaculation (rapid ejaculation) „ Ejaculation occurring before the man or partner wishes it to „ Prevalence rates

„ 21% of adult males may meet criteria for premature ejaculation „ Most prevalent sexual dysfunction in adult males „ Most common in younger, inexperienced males, and declines with age „ How soon is too soon?

Sexual Pain Disorders

„ Marked Pain During Intercourse „ Dyspareunia „ Extreme pain during intercourse „ Adequate sexual desire, and ability to attain arousal and orgasm „ Must rule out medical reasons for pain „ Prevalence:

„ 1% to 5% of men

„ 10% to 15% of women

Sexual Pain Disorders

„ Vaginismus „ Limited to females „ Outer third of the vagina undergoes involuntary spasms „ Complaints include feeling of ripping, burning, or tearing „ Prevalence rates:

„ 5% of women seeking treatment (in US)

„ rates higher in more conservative countries and subgroups

6 Assessing Sexual Behavior and Sexual Dysfunction „ Comprehensive Interview „ Include a detailed history of sexual behavior, lifestyle, history, expectations, and associated factors „ Medical Examination „ Must rule out potential medical causes of sexual dysfunction

Assessing Sexual Behavior and Sexual Dysfunction „ Psychophysiological Evaluation „ Exposure to erotic material „ Determine extent and pattern of physiological and subjective sexual arousal „ Males – Penile strain gauge (plethysmograh) „ Females – Vaginal photoplethysmograh

Etiology of Sexual Dysfunctions

„ Biological Contributions „ Physical disease and medical illness „ Circulatory problems „ Prescription medications „ SSRIs and other non-psychotropic medications „ Use and abuse of alcohol and other drugs „ Alcohol

„ Methamphetamine

„ Exstasy

7 Etiology of Sexual Dysfunctions

„ Psychological Contributions „ The role of “anxiety” „ The nature and components of performance anxiety „ Performance pressure - pressure to perform, to do it right

„ implicit assumption that one should already know how to do everything

„ problem is: you want to do it right but are afraid to ask „ Spectatoring - watching self (not mirrors)

Etiology of Sexual Dysfunctions

„ Psychological Contributions „ Other anxiety issues include „ fear of being caught „ acquiring a disease „ becoming pregnant „ guilt „ Interpersonal problems „ anger at a partner or trust problems „ communication problems really get in the way of sex

Etiology of Sexual Dysfunctions

„ Personal psychological histories „ Negative or traumatic sexual experiences „ Social and Cultural Contributions „ Erotophobia

„ learned negative attitudes about sexuality

8 Psychosocial Treatment of Sexual Dysfunction „ Education alone „ Surprisingly effective „ Masters and Johnson’s Psychosocial Intervention „ Education „ Eliminate performance anxiety „ Sensate focus and nondemand pleasuring

Psychosocial Treatment of Sexual Dysfunction „ Additional Psychosocial Procedures „ Squeeze technique

„ Premature ejaculation „ Masturbatory training

„ Female orgasm disorder „ Exposure to erotic material

„ Low sexual desire problems

Medical Treatment of Sexual Dysfunction „ Erectile Dysfunction „ Viagra „ Vasodilator „ CANNOT be on alcohol or other drugs „ Will not simply cause erection – must receive stimulation „ Will not address issue of desire „ Injection of vasodilating drugs into the penis „ Penile prosthesis or implants „ Vascular surgery „ Vacuum device therapy „ Few medical procedures exist for female Sexual Dysfunction

9 Gender Identity Disorder

„ Also known as Transsexualism „ NOT the same thing as transvestite or transvestic festishism „ Characteristics „ Person feels trapped in the body of the wrong sex „ Often times have desire to get rid of primary sex characteristics „ get rid of penis, facial hair, or breasts, etc. „ in last 25 years medical procedures have been developed to get change or eliminate these characteristics

Gender Identity Disorder

„ Take on the persona of, and live as other gender „ Assume the identity of the desired sex, but the goal is not sexual „ transvestites dress as women but are sexually excited by this „ Causes are unclear „ Gender identity develops between 18 months and 3 years of age

Gender Identity Disorder

„ Three patterns seen in GID „ 1) males aroused by males „ these individuals do not regard themselves as homosexuals

„ see self as heterosexual because they see themselves as a woman „ 2) male GID aroused by females „ less common - may see self as homosexual „ 3) see GID that are asexual

10 Gender Identity Disorder

„ GID is not very common (despite media coverage) „ more common in males than in females „ not sure why this is the case

„ chromosomal explanations and inutero exposure to either male or female hormones to an excessive amount

Gender Identity Disorder

„ Gender identification cannot be unlearned „ Little to no evidence that you can talk a GID out of problems (psychotherapy) „ because psychotherapy doesn't change one's orientation: a medical technique arose

Gender Identity Disorder

„ Sex reassignment surgery „ must have two years of counseling „ For man- must live as a female first, then can do surgery if he is successful at living as a woman „ much easier to turn a male into a female „ 75% report satisfaction with new identity

„ Female-to-male conversions adjust better than male- to-female

„ Even after surgery, male-to-female often report feeling depressed & confused about their identity

11 Sexual disorders

Sexuality continuum

“Normal” Atypical Paraphillic

Paraphilias: An Overview

„ Nature of Paraphilias „ Sexual attraction and arousal to inappropriate people, or objects

„ Includes a huge range of attractions from illegal and nonconsensual to violent to objects „ Often multiple paraphilic patterns of arousal „ High comorbidity with

„ Anxiety

„ Mood

„ Substance abuse disorders

12 Paraphilias: An Overview

„ Main Types of Paraphilias „ Fetishism „ Voyeurism „ Exhibitionism „ Transvestic fetishism „ Sexual sadism and masochism „ Pedophilia

Pedophilia

„ Pedophilia and pedophiles „ Sexual attraction to young children „ Incest

„ Sexual attraction to one’s own children „ Both may involve male and/or female children or very young adolescents „ Prevalence „ Rates difficult to determine „ Pedophilia is rare, but not unheard of, in females

Pedophilia

„ Most pedophiles and incest perpetrators are male „ Most are repeat abusers „ Under situations where remove the consequences for those caught – most will say that they abused many, many more that no one knows about „ Incestuous males may be aroused to adult women „ This is not typically true for pedophiles

13 Pedophilia

„ Most rationalize the behavior and engage in other moral compensatory behavior „ Upstanding citizens „ Clergy „ Doctors „ Many do not appreciate their power and do not recognize the damage being done

Pedophilia

„ Causes of Pedophilia „ Unclear what is causing this

„ Has been with humans for thousands of years „ Pedophilia is associated with sexual and social problems and deficits „ Patterns of inappropriate arousal and fantasy may be learned early in life „ Many have history of sexual abuse as children

„ Note the importance of predicting into this group

„ Many children are abused Æ few go on to pedophilia

Pedophilia: Treatment

„ Psychosocial Interventions „ Most are behavioral and target deviant and inappropriate sexual associations „ Covert sensitization „ Imaginal procedure involving aversive consequences „ Orgasmic reconditioning „ Associate masturbation with appropriate stimuli „ Family/marital therapy „ Address interpersonal problems „ Coping and relapse prevention „ Teaches self-control and coping with risk „ Some introduction of addiction strategies here

14 Pedophilia: Treatment

„ Efficacy of Psychosocial Interventions „ About 70% to 100% of cases show improvement „ Most pedophilias run a chronic course and relapse rates are very high

„ Recidivism occurs very often

Pedophilia: Medical Treatment

„ Medications: Chemical castration „ Often used for dangerous sexual offenders „ Types of available medications „ Cyproterone acetate „ Anti-androgen, reduces testosterone, sexual urges and fantasy „ Medroxyprogesterone acetate „ Depo-provera, also reduces testosterone „ Triptoretin „ A newer and more effective drug that inhibits gonadtropin secretion

Pedophilia: Medical Treatment

„ Efficacy of medication treatments „ Drugs work to greatly reduce sexual desire, fantasy, arousal „ Relapse rates are high with medication discontinuation „ Psychologists and society do NOT know how to treat this

„ May be part of the “wiring” or “orientation” „ Requirement to notify members of community

15 Fetishism

„ Fetish continuum ...... MILD STRONG NECESSITY SUBSTITUTE PREFERENCE PREFERENCE FOR HUMAN Considered “Abnormal”

Fetishism

„ Fetishism „ Sexual attraction to nonliving objects

„ i.e., inanimate and/or tactile „ Numerous targets of fetishistic arousal, fantasy, urges, and desires „ Examples

„ underwear, silk, rubber, shoes, boots

„ NOT if female clothing used exclusively in cross- dressing „ Often a person is replaced by an attraction to an object

Fetishism: Etiology

„ psychoanalytic „ castration anxiety (not oedipal here) „ replace sex-with-female with sex-with-object so that female may not castrate them

16 Fetishism: Etiology

„ Learning theory (behaviorism) „ Classical conditioning

„ pairing of arousal and/or orgasm (masturbation) in the presence of objects „ Operant conditioning

„ orgasm is a big reinforcer

„ coupled with the CC adds to the explanation for why fetishist seeks out the things that he or she is attracted to

Transvestic Fetishism

„ Transvestic Fetishism „ Estimated prevalence: 1-5% for men „ This is NOT the same thing as homosexuality „ Sexual arousal with the act of cross-dressing „ Males may show highly masculinized compensatory behaviors „ Many are married and the behavior is known to spouse „ Many have extreme guilt about this

Voyeurism & Exhibitionism

„ Voyeurism „ Practice of observing an unsuspecting individual undressing or naked „ Risk associated with “peeping” is necessary for sexual arousal „ Exhibitionism „ Exposure of genitals to unsuspecting strangers „ Element of thrill and risk is necessary for sexual arousal

17 Sexual Sadism & Masochism

„ Sexual Sadism „ Inflicting pain or humiliation to attain sexual gratification „ Sexual Masochism „ Suffer pain or humiliation to attain sexual gratification „ NB: having fantasies does not make you have this disorder - must engage in the disorder

Sexual Sadism & Masochism

„ Relation between sadism and rape „ Sadism does NOT include rape

„ this involves consenting partners „ Some rapists are sadists, but most do not show paraphilic patterns of arousal „ Rapists show sexual arousal to violent sexual and non-sexual material

Frotteurism

„ Person is sexually aroused by touching or rubbing against a non consenting person „ wait for crowded situation - elevator, subway „ do it subtlety, so victim doesn't know what's happening „ Prevalence shifts depending on part of country „ Some countries report higher prevalence rates

18 Miscellaneous paraphilias

„ telephone scatalogia „ lewdness „ necrophilia „ corpses „ partialism „ exclusive focus on a part of the body „ zoophilia „ animals „ … more???

Miscellaneous paraphilias

„ Are you sure??? „ klismaphilia „ enemas „ urophilia „ urine „ corprophilia „ feces

What is abnormal?

„ Keep in mind issue of consenting partners „ Consider what is connecting you to a partner and what is distancing „ When safe, legal, and ethical „ Have fun „ But hey, keep it clean will you?

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