Overview Sexual Difficulties: An LGBT perspective • Sexual response cycle • DSM IV • ‘Sexual dysfunction’ vs ‘cultural Dr Naomi Adams dysfunction’ Clinical Psychologist • Incidence Mortimer Market Centre • A New View • Causes The Sexual Response Cycle – The Sexual Response Cycle Masters & Johnson (1966) Kaplan (1974) • Appetitive (Desire) - fantasies about sexual Desire activity and a desire to have sexual activity • Excitement (Arousal) - subjective sense of sexual pleasure & accompanying physiological changes Arousal • Orgasm - a peaking of sexual pleasure, release of sexual tension, rhythmic contractions of perineal muscles and reproductive organs and ejaculation Orgasm in men • Resolution - muscular relaxation and sense of Resolution well-being 1 Sexual Response Cycle cont. Sexual Dysfunction – DSM-IV “The sexual dysfunctions are characterised by a • Assumes that heterosexual penetration and disturbance in sexual desire and in the orgasm is the universal script for men and psychophysiological changes that characterise the women (Boyle 1994), the “doing it” theory sexual response cycle and cause marked distress of sexual normality and the “didja come” and interpersonal difficulty” theory of sexual satisfaction (Ogden 2001) Distinction between: • Assumes that there is linear progression – Primary vs Secondary between stages and stages are discrete – General vs Situatiunal • Notion of ‘Willingness’ (Loulan) – Organic vs Psychogenic Sexual Dysfunctions – DSM-IV DSM: critique Women Men • Hypoactive sexual • Hypoactive sexual • How we conceptualise normal functioning will desire desire determine what we see as a problem • Sexual aversion • Sexual aversion • Penetrative vaginal intercourse and orgasm may • Impaired sexual • Male erectile disorder not be the ultimate goal for many LGBT clients! arousal • Male orgasmic • No equivalent of ‘premature orgasm in women’ • Female orgasmic disorder • Vaginisimus assumes vaginal penetration disorder • Premature ejaculation • No category for painful anal penetration: analisimus / anodyspareunia • Dyspareunia • Dyspareunia • Difficulty overcoming gag response in fellatio • Vaginisimus • Painful ejaculation 2 Whose Problem? Whose Problem? • Historical Perspectives – Religious influences • Freud (sexuality dangerous force, gender roles clearly defined) • Sex for procreation • Homosexuality treated • All pleasure sinful • 1950s Alfred Kinsey (men & women naturally different, sex • Homosexuality a sin ok, homosexuality more ‘normal’) – 19th Century Science • 1967 Homosexual acts decriminalised. Stonewall riots. Gay rights movement begins. • Only heterosexual vaginal penetration ‘normal’ • 1970s Masters and Johnson (men & women similar, learned • masturbation, oral sex‘disorder’ -> damage) skill) • Plethora of devices available to stop children masturbating • 1970s Feminism – 20th Century • 1980s Lesbian sex wars • Ellis (‘nyphomania’ treated, sign of madness) ‘Dysfunction’ vs Difficulty? Charting the sexual map(s) • Unhelpful (blaming?) when problem may be • No one size fits all adaptive • “Need to include the sexual experiences of not • 80% women do not have orgasm during just women, but lesbians, FtMs, MtFs, cross- penetrative sex alone dressers, 3rd genders, femme tops, butch bottoms, • What is ‘normal’ and who defines it? pre-op, post-op, bois and daddies…” • Focus on individual, not context, e.g. relationship • Huge variety of micro-climates, temperate and • Medicalising – pathologising sexuality chilly, permanent and semi-permanent… • Reductionist – rich varied human experience • Different zones, even for one person… 3 There’s more to sex than boi meets grrl… Incidence: Heterosexual Women • Zones for.. earthmoving sex, silly sex, mood- • Female sexual difficulties (Michael, Gagnon, elevating sex, sorrowful sex, placating sex, Laumann and Kolata 1994 N=3159, Hawton relaxing, energising sex, barter sex, signature sex 1985) (statement of culture or identity), solo sex, sex for – Loss of libido 32% 52% intimacy, sex for distance, sex-free zones, – Lack of lubrication 18% mechanical sex, once-a-month-if-we-feel-like-it sex-or-not ritual sex, only-if-I-don’t-have-to-lift-a- – Anorgasmia 24% 19% finger sex and patches of ‘willingness’ – maybe – Dyspareunia 15% 4% I’ll feel like it after we start… – Vaginisimus 18% Incidence: Lesbians Audre Lorde Study • Very little empirical data (M&J similar) Heterosexual Lesbian • High levels of inhibited sexual desire Non-communication 20 4.4 Infrequency 28 21.9 (lesbian bed death) & desire discrepancy Dissatisfaction 7 0 • Low levels of vaginisimus Dissatisfaction (m) 8 0 • Lesbians prefer to have sex >often than het Avoidance 18 4.6 women > het men > gay men Non-sensuality 22 6.6 Vaginisimus 25 15.5 • But higher satisfaction, more freq orgasms Anorgasmia 22 2.3 Total 9 0 4 Incidence: Heterosexual Men Incidence: Gay Men • Male sexual difficulties (Michael, Gagnon, • Very little empirical data (M&J similar) Laumann and Kolata 1994 N=3159; Hawton 1985) • Premature Ejaculation less common • Retarded E more common – Erectile dysfunction 11% 60% – Premature ejaculation 28% 16% • Difficulties more common with RMPs – Retarded ejaculation 9% 6% rather than CMPs – Loss of libido 16% 6% – Pain during sex 9% Concurrent Sexual Difficulties Causes: Biological • Warner et al (1987) • Biological – 15% of men with erectile failure also felt that – disorders of the nervous system (eg MS) premature ejaculation was a problem – endocrine system disorders (diabetes) – 18% of men with premature ejaculation also had – vascular problems (circulatory difficulties) erectile problems – other physical illnesses (eg HIV) – 35% of men with low interest also had erectile failure – surgery (spinal cord etc) – 20% of women with low interest also reported – drugs (esp BP, benzodiazepines, anti-depressants, orgasmic difficulties ARTs, recreational drugs and alcohol) • Sexual problems in sexual partners 5 Causes: Individual Causes: Anxiety • Individual • Interferes with arousal – Developmental factors (attitudes to sex and intimacy, – Peripheral autonomic effects physical affection, knowledge, access to info) – Self-concept (identity, confidence, body-image, – Anxiety and physiological inhibition of genital attractiveness) responses co-exist, response to perceived threat – Stressful life events, eg disclosure – Sexual responses are inhibited to avoid anxiety – Childhood sexual abuse and sexual assault – Sexual orientation or preferences (if in conflict), • Anxiety increases with performance fears interaction with shame. – Fear of failure, ridicule, pregnancy, – Mood and emotional difficulties size/appearance of genitals, fear of STIs/HIV – Anxiety – central role in cause and maintenance Causes: Contexual Causes: Relationship Factors • Contexual • Sexual difficulties often reflect relationship – Physical environment (space, time, privacy) difficulties – Cultural beliefs and prevailing norms (sex is • Sexual problems may be serving a function bad/sinful, sex and disability, sexual double • Difficulties may be caused by: standards, narrow definitions of sexual – Resentment, trust issues, love/sex difficulties, behaviour – sex=penile-vaginal intercourse) low attraction, anger, poor sexual skills, – Relationship factors communication difficulties, infidelity, conflicts in sexual values, gender role conflicts, sexual problem in partner 6 A New View: Leonore Tiefer The New View Classification Critique of APA and FSD The Working Group on a New View of • False equivalency between men and women Women’s Sexual Problems defines sexual – women do not usually separate desire and arousal, problems as subjective arousal more important than physical arousal “discontent or dissatisfaction with any emotional, • False equivalency between women physical, or relational aspect of sexual • Sex is Relational experience, which may arise in one or more of the – The value and satisfaction gained from sexual activity following interrelated aspects of women’s sexual is often relational - a desire for intimacy, a wish to lives.” please a partner, or avoid offending or losing a partner The New View Classification The New View Classification 1. Sexual Problems due to Socio-cultural, Political or Economic Factors A. Ignorance and anxiety due to inadequate sex education, 2. Sexual Problems Relating to Partner and lack of access to health services or other social Relationship constraints (vocabulary, information, gender) A. Inhibition, avoidance, or distress arising from betrayal, B. B. Sexual avoidance or distress due to perceived dislike, fear, partner’s abuse or couple’s unequal power inability to meet cultural norms regarding correct or B. Discrepancies in desire or preferences ideal sexuality (body image, sexual desire etc) C. Ignorance or inhibition about communicating C. C. Inhibitions due to conflict between the sexual norms preferences or initiating, pacing or shaping sexual on one’s sub-culture or culture of origin and those of the activities dominant culture D. Loss of interest and reciprocity as a result of conflicts D. D. Lack of interest, fatigue, or lack of time due to family over money, schedules, relatives, or from traumatic and work obligations experiences, e.g. infertility E. Inhibitions or arousal or spontaneity due to partner’s health status or sexual problems 7 The New View Classification The New View Classification 4. Sexual Problems due to Medical Factors Pain or lack of physical response during sexual activity 3. Sexual Problems due to Psychological Factors despite a supportive and safe interpersonal