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Chapter 1 Topics in : Sexuality Across the Lifespan Childhood and

Introduction

Take a moment to think about your first sexual experience. Maybe it was an experience of early , “playing doctor” or “show me yours and I’ll show you mine.” Many of us do not think of childhood as a time of emerging sexuality, although we likely think of adolescence in just that way. But the assumption that sexuality begins in adolescence is incorrect. Human sexual development is a process that occurs throughout the lifespan. There are important biological and psychological aspects of sexuality that differ in children and adolescents, and later in and the elderly.

In an early but seminal work on child sexuality Moglia & Knowles (1997) make a powerful statement. They state: from the moment they are born, infants are learning about their bodies, learning how to love and who to trust. Parents are their primary educators about sexuality, and mental health professionals often are called upon to guide these conversations. Like others who write about sexuality in childhood, these authors recognize that sexuality begins early and that parents play a pivotal role in educating children about their sexuality and about sexual expression. As clinicians working with families, it is important to be able to respond to questions regarding what is “normative” and to establish the foundation of healthy sexuality.

This chapter will review the development of sexuality using a lifespan perspective. It will focus on sexuality in infancy, childhood and adolescence. It will discuss biological and psychological milestones as well as theories of attachment and psychosexual development.

Educational Objectives

1. Define sexuality and the elements that make up sexuality 2. Discuss sexuality in children from birth to age two 3. Describe Freud’s theory of psychosexual development 4. Describe the development of attachment bonds and its relationship to sexuality 5. Describe early childhood experiences of sexual behavior and how the child’s natural sense of curiosity leads to sexual development

6. Discuss common types of sexual play in early childhood, including what is normative

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7. Discuss why it is now thought that the idea of a latency period of sexual development is inaccurate 8. Discuss differences in masturbation during adolescence for males and females 9. Discuss the stages of gay identity development 10. Discuss issues related to the first sexual experience

11. Discuss teen

What is Sexuality?

Prior to looking at sexuality in children, it is important to look at an overall definition of sexuality. In the broadest sense, sexuality is defined as people's interest in and attraction to others, their capacity to have erotic experiences and responses. While children are not attracted to others in an erotic way, even at a very young age they are capable of biological and sensual (pertaining to the senses and pleasure) responses. These sensual experiences form the basis of early sexuality.

Moglia and Newman (2008), discuss a number of interrelated factors that are a part of sexuality:

• sexual anatomy, physiology, growth and development • sexual orientation and attraction • sexual behaviors & lifestyles, beliefs, attitudes & values • body image and self-esteem (body image can have a profound effect on healthy relationships) • sexual health • sexual fantasies and dreams • intimate relationships • life experiences as they relate to sexuality • spirituality as it relates to sexuality • gender, gender identity and gender role identity (the idea of how we should behave because we are a female or male).

Sexuality is an integral part of who we are, what we believe, what we feel, and how we respond to others.

These components are broad, and apply to individuals throughout the lifespan. They also interact with one another in complex ways.

Freud’s Contributions to Our Understanding of Sexual Development

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Prior to 1890, it was widely thought that sexuality began at . This changed with the theories of Sigmund Freud. While in many ways Freud was a product of his times, many aspects of his theories are applicable to our current study of sexuality.

Freud’s theory, aptly known as the psychosexual theory of development, involves the idea that personality development is centered on the effects of the sexual pleasure drive on an individual’s psyche, thus sex is a major motivational factor in life. The term libido refers to a person's drive or desire for sex. Freud looked at the physiological/physical aspects of libido, as well as the psychological and social aspects, and the often complex interactions between the two. Even in very young children who are experiencing physical sensations there is also an emotional component. For example, the mother’s cuddling of her child and the skin to skin contact in are among many peoples’ earliest sensual experiences. Freud’s theory is a stage theory, and he further identifies that at each stage of development a particular body part is most sensitive to erotic stimulation. These erogenous zones are the mouth, the anus, and the genital region. In the example above, Freud identifies the mouth as the primary erogenous zone. In 1905 Freud published Three Essays on the Theory of Sexuality, which looked at sexuality and links between early childhood experiences and behavior and personality. The book was a series of essays. In the essay entitled, “Infantile Sexuality,” Freud theorized that sexual feelings were present in the child from the moment of birth. He states:

One feature of the popular view of the sexual instinct is that it is absent in childhood and only awakens in the period of life described as puberty. This, however, is not merely a simple error but one that has had grave consequences, for it is mainly to this idea that we owe our present ignorance of the fundamental conditions of sexual life … So far as I know, not a single author has clearly recognized the regular existence of a sexual instinct in childhood; and in writings that have become so numerous on the development of children, the chapter on “Sexual Development” is as a rule omitted.

Freud writes that even in infancy, sensuality and sensual experience is a primary driving force. Parental and societal prohibitions against early sexuality result in conflicts for the child and form the basis of adult personality. According to Freud, the child must resolve a conflict during each psychosexual stage in order to advance to the next stage. If that conflict is not resolved, the child will fixate in this stage, and this will affect the child’s adult personality. While the field of mental health no longer subscribes to these theories in total, themes such as the importance of sensual gratification and parental acceptance of sexuality continue to resonate.

Sexuality In Childhood (Birth To Age 2)

Emotional Response

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The first intimate relationship that children experience is with the mother or the primary caretaker. This relationship involves many of the tactile senses and includes being rocked and cuddled, being bathed, cleaned and diapered. These experiences may establish preferences for certain kinds of stimulation that persist throughout life. Physical Response Children experience pleasure in their bodies from birth onwards. People are born with the physical ability to experience sexual response. Male infants, for example, get , and in fact, boy babies are sometimes born with erections. Vaginal lubrication has been found in female infants in the 24 hours after birth (Masters, Johnson, & Kolodny, 1982). Infants and young children have many other sensual experiences, including sucking on their fingers and toes, and exploring their bodies, including their genitals. Fetal masturbation has been described in males in utero (Rodríguez, López & Cajal, 2016). Studies of very young female children have shown that young girls masturbate as early as three to fifteen months (Rödöö & Hellberg, 2013).

Masturbation Masturbation is defined as “erotic stimulation especially of one's own genitals.” Masturbation is a common human behavior, said to occur in 90–94% of males and 50–60% of females at some time in their lives (Nechay, Ross, Stephenson & O'Regan, 2004). There is a vast difference in the views that societies and cultures hold of masturbation. The term masturbation is derived from the Latin words manus, meaning “hand” and stupratio, meaning “defilement”. This suggests that the practice of masturbation was thought to be unclean. In the professional literature, discussions of “infantile masturbation” portray the behavior in ways ranging from an ordinary behavior to a disorder (for example, Nechay, Ross & Stephenson et al., 2004, discuss what they term “gratification disorder.”). Infants have been observed fondling their genitals, and the rhythmic type of manipulation associated with adult masturbation appears early. The study cited in the previous section (Rödöö & Hellberg, 2013) lists such observations as early as 3 months after birth while others (e.g., Martinson, 1994) place the onset of gratification-oriented masturbation at age 2 1/2 to 3. While we cannot truly know the infant/young child’s goal with self- stimulation, it is thought to be pleasurable. In fact, there are cultures in which parents fondle infant’s genitals in order to keep them quiet (Hyde & DeLamater 2003) and soothe them in some ways (see, for example, Ahn & Gilbert, 1992). from masturbation are possible even at a young age although boys cannot actually ejaculate until puberty. Masturbation, even at this age, is both normative and may even be optimal. This was discovered as early as the 1940s through the work of Rene Spitz, an attachment theorist who studied the effects of inappropriate experiences of early care. Spitz (1949) compared infants with optimal and dysfunctional relationships with their mothers. He found that those infants with more optimal relationships were more likely to engage in masturbation, reinforcing the idea that masturbation is normative and healthy.

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Infant masturbation tends to be a singular experience, but it is not uncommon for infants to masturbate alongside one another, reminiscent of the idea of parallel play. In later infancy there may be some infant to infant sexual encounters, in which children may pat, stroke or gaze at one another (Hyde & DeLamater, 2003; Lidster & Horsburgh, 1994.) Freud’s Oral Stage of Development (Birth to One and a Half)

The first stage of Freud’s psychosexual stages is the oral stage of development. This stage begins at birth. During the oral stage, the mouth the primary focus of libidal energy. Nursing infants derive pleasure from sucking and accepting things into the mouth. Should difficulties occur at this stage, such as problems with nursing, the adult may develop an oral character. The oral stage culminates in the primary conflict of weaning, which concludes the sensory pleasure of nursing. This stage lasts approximately one and one-half years (Freud, 2010; Gabbard, 2010). Freud’s Anal Stage of Development (One and One-half to Two Years)

At one and one-half years, the child enters the anal stage. This stage generally coincides with the beginning of toilet training. According to Freud, the child becomes preoccupied with the erogenous zone of the anus and with the retention or expulsion of feces. There is a conflict between the id-driven compulsion and pleasure connected with the expulsion of bodily wastes, and the ego and superego, which represent parental and societal pressures to control bodily functions. Struggles around toileting may result in an anal fixation, leading to anal character traits. This stage lasts from one and one-half to two years (Freud, 2010; Gabbard, 2010). Attachment

Freud’s theory discusses the idea of attachment in only a peripheral way. Attachment theorists such as Bowlby (1988) and Ainsworth felt that psychoanalytic theory failed to see attachment as a psychological bond in its own right rather than an instinct derived from feeding or sexuality. These theorists look at the bonds between infant and caregiver as a pivotal organizing factor in the child’s later capacity for relationships. Attachment theorists look not only at an individual’s later emotional adjustment but also his or her ability to relate sexually (Richardson, 2004). Early non-genital sensual experiences, such as rocking and cuddling, promote attachment bonds. These begin shortly after birth. The quality of these attachments, whether stable or secure or insecure and frustrating, seems to affect a person’s capacity for adult attachment as well as adult sexuality (Bowlby, 2004). Gender Identity Development

Gender identity refers peoples’ personal sense of their own gender. While gender and sexuality are two very different things, and people of any gender identification develop diverse sexual and affectional choices, it’s helpful to look at the concept of gender within our discussion of child and adolescent development. In our binary culture, gender is often viewed a binary choice (male or female) but the US is beginning to expand this definition as a society. Gender identity may be associated as masculine or feminine, or some

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6 combination thereof. A person or child’s gender identity can be consistent or inconsistent with their biological sex characteristics (Morrow & Messenger, 2006). There are a number of theories that explain gender identity development. These theories take into account both biological and social factors. One of the earliest theories was that of Lawrence Kohlberg (1996), who proposed a state theory of gender identity development. In Kohlberg’s theory, children move though various stages of understanding. These stages are: Gender Labeling (age 2-3.5 years), Gender Stability (3.5-4.5 years) and Gender Constancy (6 years). These stages are aptly named. Other theories of gender identity development are Bem’s Gender Schema Theory (1981), a cognitive theory to explain how individuals become gendered in society, and how sex-linked characteristics are maintained and transmitted to other members of a culture and Bandura’s Social Learning Theory, proposed by Bandura as a way of explaining how children acquire their gender identity based on the influence of other people, particularly their parents (ScienceAid, n.d.).

Most of these theories agree that children begin to recognize gender differences and can identify themselves as male or female as early as about age 2 ½, They can generally identify which parent they are most like physically. Although initially their ability to differentiate genders is related to clothing style or hair, by age 3 there is awareness that genitals play a role in gender differentiation. There may be an interest in exploring these differences with other children (Martinson, 1994).

Child

Sexuality In Early Childhood (Ages 3 to 7) The early childhood years are marked by an increased interest in the environment as well as an increase in sexual exploration. As children become more social beings, their sexual interactions expand from self-focused activities, such as genital stimulation and masturbation, to other-focused activities. By interacting socially, children begin to understand what is socially acceptable and to learn privacy boundaries. For example, although the incidence of masturbation continues in frequency, children begin to learn that that masturbation is something that is done in private. This stage also marks the beginnings of both heterosexual and homosexual behavior. They may also have an increased need for privacy while bathing and dressing (Pike, 2001). In addition to increasing social interaction, there is more curiosity about the world in general and this extends to sexual realms. For example, three and four-year-olds are curious about where babies come from and ask these difficult questions (Pike, 2001).

Increasing Curiosity About Sex

During this timeframe, and most specifically around the ages of 4 to 5, children’s sexuality becomes social. This is most frequently exhibited in play, with children holding hands and kissing, likely imitating the adults around them or media they are exposed to. In early childhood, children become more curious and they explore other children and adults'

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7 bodies because of their curiosity. At this age children have increased interest in the differences between adult and children's bodies. Pretending to be mommy or daddy and "playing doctor" become more common activities. The latter can be a somewhat controversial sexual milestone. “Playing doctor” generally involves children examining one another’s genitals or engaging in fondling or touching. This behavior is considered normative if children are willing participants and are close in age, although it can be uncomfortable for some parents, who see it as a prelude to more adult sexuality (Heins, 2004; Kennedy, 2004; Pike, 2001.)

By about age 5, most children have formed a concept of what marriage is. This comes from direct observation in their own households as well as the influence of media. The concept of marriage is specifically a platonic one at this age. Children also seem to understand the idea that people marry those of another gender, and “playing house” is common. By about age four, girls may become intensely attached to their fathers and boys to their mothers (Hyde & DeLamater, 2003; Pike, 2001), a primary factor in Freud’s phallic stage of development (to be discussed later in this section).

Some children first learn about sexual behavior by seeing or hearing parents engaged in , the so-called primal scene experience. Freud and other psychoanalytic theorists proposed that such premature sexual exposure was harmful. Although many agree with this, subsequent research may not bear it out. Studies suggests that about 20 percent of middle class children have seen their parents engaged in intercourse.

Is exposure to the primal scene harmful? Researchers at the UCLA Family Lifestyles Project attempted to study this question. The researchers studied 200 male and female children in an 18-year longitudinal outcome study. At age 17 to 18‚ participants were assessed for levels of self-acceptance, relations with peers‚ parents‚ and other adults; antisocial and criminal behavior; substance use; suicidal ideation; quality of sexual relationships; and problems associated with sexual relations. No harmful “main effect” correlates of the predictor variables were found (Okami et al., 1998).

Sexual Knowledge and Interests

At age 3 to 4 children first begin to recognize that there are genital differences between boys and girls. They notice these differences and may question them. There may be “marriage proposals to the parent of the opposite sex (Hyde & DeLamater 2003.) At about the age of 4 there is an increased interest in bathrooms and concerns about elimination. Children this age may frequently use words that refer to bowel movements and urination. It is at about the age of 5 to 6 that children in this age group begin to have more contacts outside the family. Other children may bring up new ideas about sex. Five- to seven-year- olds often increase their use of sexual or obscene language, and this is frequently to test parental reaction.

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At about the age of 7, children generally give up wanting to "marry" mom or dad. They begin to become closer to the parent of the same sex. Children in this age group become more reticent about asking questions (Pike, 2004).

Early Gay/Lesbian Behavior

During later childhood, sexual play may involve members of the same gender. This generally involves touching or fondling (Martinson, 1994). Such play is normative and does not appear to mediate the development of adult sexuality. While there is no consensus as to when children or adolescents begin to identify as gay, there is some evidence to suggest that when this does occur it remains consistent over time (Rosario et. al, 2006).

Freud’s Phallic Stage of Development

The phallic stage (ages 3–6) of development is probably the most well-known of Freud’s stages due to his theory of the Oedipus/Electra complex. In this stage, the child's erogenous zone is the genital region. It is within the context of the child’s natural curiosity about his and other people’s genitals that the essential conflict — the Oedipus complex — arises. The Oedipus complex involves the child's unconscious desire to possess the opposite-sexed parent and to eliminate the same-sexed one (Freud, 2010; Gabbard, 2010).

According to Freudian theory, the child’s identification with the same-sex parent is the successful resolution of the Oedipus complex and of the Electra complex. This is also a key psychological experience in developing a mature sexual role and identity. Freud thought that fixation at the phallic stage causes a person to be afraid or incapable of close love or a cause of homosexuality.

Sexuality in (Ages 8 to 12)

The ages of 8 to 12 reflect a transition from childhood to adolescence. For most children, it is during this timeframe that puberty occurs. While once thought to be a stage of latency in which sexual drive is dormant, Freud saw latency as a period of repression of sexual desires and erogenous impulses. According to the psychosexual theory, children transfer this repressed libidal energy into asexual pursuits such as school, athletics, and same-sex friendships. Freud thought that it was only with the onset of puberty that sexuality reawakens and the genitals once again become a central focus of libidal energy (Freud, 2010; Gabbard, 2010). Although many parents would like to believe that preadolescence is a latency period, this does not actually seem to be the case. Children’s interest in sexuality appears to remain active during this time (Martinson, 1994).

Puberty and pre-puberty

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Puberty is the physical process of sexual maturation. The term puberty is derived from the Latin word puberatum (age of maturity) and refers to the bodily changes of sexuality. In girls, puberty usually begins at 11 years of age, but may start as early as age 7. A recent study published in Pediatrics found that by age 7, about 10 percent of white and 23 percent of African-American girls had started developing . A study published in 1997 found that 5 percent of white females and 15 percent of black females had reached puberty at that age. Puberty, then, is occurring earlier.

Puberty is initiated by signals from the brain to the gonads (the ovaries and testes). These (estradiol and testosterone) stimulate the growth and function of the brain, skin, hair, breasts and sex organs. The most obvious of these changes are referred to as secondary sex characteristics, the most evident being development in females and facial hair in males.

Masturbation During preadolescence, masturbation continues to be common. This is something of a learning tool for more adult sexuality. A study conducted by Bancraft et al. (2002) found that 40 percent of college women and 38 percent of men reported masturbating during these years. For young women the road to masturbation is generally self-discovery; males learn about masturbation from peers.

Sexuality in Preadolescence Research continues to confirm that the preadolescent years are not ones in which most children actually engage in sexual behaviors. The percentage of children who had initiated sexual intercourse before age 14 has actually decreased in recent years, from a high of 8 percent of girls and 11 percent of boys in 1995 to a low of 6 percent of girls and 8 percent of boys in 2002 (Abma et. al, 2004).

There is some thought that the separation of young men and women into social groups is one mediating factor in preventing premature sexual contact. This is a time period in which young men and women hear about sex and learn about sex but do not engage in sex (Hyde & DeLamater, 2003). Because children are socializing primarily with others of the same sex, sexual exploration with same sex peers is normative. These activities involve masturbation, exhibitionism and fondling of one another’s genitals (Hyde & DeLamater, 2003). During preadolescence, many children begin “dating” for the first time. Dating is generally a group activity. Boys, who mature less quickly, are often slow to initiate kissing or other physical activities, although games involving kissing may be part of social gatherings or parties.

Sexuality in Adolescence (Age 13 to 19)

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Of all the developmental timeframes discussed so far, adolescence is indisputably the time in which sexual maturation, interest and experience surge. This increased interest is caused by continued focus and awareness of body changes and rising hormone levels. There is also the cultural expectation that teens begin to prepare for more adult roles through dating and some degree of more intimate contact, which may or may not be sexual intercourse.

Since 1991, there have been declines among high schoolers in the percentages of students who ever had sexual intercourse, who had sexual intercourse for the first time before age 13, who have had sexual intercourse with four or more persons in their lifetime, and who report being currently sexually active.

Widespread concerns about adolescents' exposure to sexually explicit images sent by smartphone or internet — commonly known as "sexting" — appear to be based on exaggerated reports. A national survey of 1,560 minors aged 10-17 revealed that roughly 7 percent had received "nude or nearly nude" pictures or videos, and only about 2 percent had appeared in or created such images. Females were more likely to create or appear in such images, and over half of such images were generated between senders and recipients as part of a romantic relationship. Few minors reported distributing these images widely.

For both young men and young women testosterone level seems to have an affect on sexual activity. For young men this relationship is very strong. For young women it appears that testosterone levels, rather than levels of estrogen or progesterone levels, was related to sexuality. For girls, pubertal development (developing a womanly figure) also had an effect on sexuality (Hyde & DeLamater, 2003).

Freud’s Genital Stage of Development (puberty onwards)

In the genital stage libidinal energy once again focuses on the genitals and interest turns to relationships, specifically to romantic and sexual relationships with peers. This stage spans both adolescent and adult years. Masturbation

One of the most important sources for statistics on sexuality is the Kinsey Report. Kinsey states: "Masturbation was the most important sexual outlet for single females and the second most important sexual outlet for married females, providing 7-10% of orgasms for those 16-40. Although these numbers include data that spans a wider age group than only adolescents age group (Gebhard, & Johnson1979/1998; Kinsey, 1948/1998; Kinsey, 1953/1998).

According to the Kinsey data, there is a rise in masturbation in boys between the ages of 13 and 15, with about 85-90% of young men between these ages reporting masturbation. At about this age boys actually masturbate to . The Kinsey studies also found that although some girls also began to masturbate at that age, only about 20% do. Masturbation in women actually peaks at age 30 and remains level from this point (Kinsey, 1948/1998; Kinsey, 1953/1998).

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Lesbian and Gay Sexual Behavior

About 10 percent of college-age men and 6 percent of women report having one same gender partner in high school (Bancroft, Herbenick & Reynolds, 2002). Same-gender adolescent sexual experiences do not necessarily signal a lesbian, gay, or bisexual identity (Blumenfeld & Raymond, 1993).

While there is a difference between engaging in sexual relationships with others of the same gender, and identifying as LGB, statistics show that there are many teens and young adults who identify on the LGBT spectrum. Twice as many young adults identify as lesbian, gay, bisexual, or transgender (LGBT) compared to older adults. A 2013 survey found 6.4% of adults ages 18 to 29 identified as LGBT compared to 3.2% of 30 to 49 year olds (Kaiser Family Foundation, 2014).

While traditionally mental health professionals have attempted to group sexual behavior into models, there is growing recognition of the experience and diversity of sexual orientation beyond “heterosexual,” “gay,” and “lesbian” identities, and this recognition has led to challenges to the traditional stage models of sexual orientation identity development (Bilodeau & Renn, 2005).

Research on adolescents and sexual orientation supplements the stage models with information specific to youth and college students. Research on teenage youth notes a trend in which self-identification as lesbian, gay, or bisexual happens at increasingly earlier ages (Troiden, 1998).

D’Augelli (1994) offers a “life span” model of sexual orientation development. This model suggests that sexual orientation may be very fluid at certain times in the lifespan and more fixed at others and that human growth is intimately connected to and shaped by environmental and biological factors. The D’Augelli model describes six “identity processes” that operate more or less independently and are not ordered in stages:

• Exiting heterosexuality • Developing a personal LGB identity • Developing a LGB social identity • Becoming an LGB offspring • Developing an LGB intimacy status • Entering an LGB community

First Sexual Experience

The teen years are often the time when young men and women have their first sexual experience. The median age at first intercourse is 16.9 years for boys and 17.4 years for girls (Alan Guttmacher Institute, 2002). The percentage of 9-12th grade students who report having had four or more sexual partners has declined in recent years from 19

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12 percent in 1993 to 14 percent in 2003. Six percent of all U.S. high school students, however, had sexual intercourse before age 13. Males (18%) are more likely than females (11%) to report having had four or more sexual partners. Black youth aged 15-21 report first sexual intercourse at ages earlier than their White, Hispanic/Latino, or Asian counterparts (Advocates for Youth).

For those youth who are sexually active, the first sexual intercourse is a major transition both psychologically and socially (Hyde & DeLamater, 2003). There appear to be gender difference in the experience of first sexual intercourse with young men reporting more sexual pleasure and less guilt than young women. Attitudes towards premarital intercourse generally fall into four categories (Reiss, 1960).

1. Abstinence: a standard in which premarital sexual intercourse is considered wrong, regardless of circumstances 2. Double Standard: a standard in which males are considered to have greater right to premarital intercourse. 3. Permissiveness without affection: a standard in which premarital intercourse is considered right for both sexes regardless of emotional involvement 4. Permissiveness with affection: a standard in which premarital intercourse is considered right for both sexes if part of a committed relationship

There seems to be somewhat of a trend towards more casual sexual encounters beginning during adolescence and continuing in college. This phenomenon is colloquially known as friends with benefits, in which two people may have a sexual relationship without demanding or expecting the commitment of a romantic relationship. “Sexting” is the exchange of explicit sexual messages or images by mobile phone. More than one in ten (13%) 14 to 24 year olds report having shared a naked photo or video of themselves via digital communication such as the internet or text messaging (AP/MTV, 2011). Grello, Welsh, and Harper (2006) studied the circumstances associated with casual sex encounters, in order to identify the link between casual sex, depressive symptoms, and infidelity among college students. They found that casual sex was a common occurrence. First sexual experiences took place more frequently with a casual sex partner and was frequently connected with drug use and alcohol consumption. Casual sex occurred more often between “friends” than with strangers. Males who engaged in casual sex reported the fewest symptoms of depression, and females who had a history of casual sex reported the most depressive symptoms.

Another frequently seen occurrence was that of serial monogamy in which premarital sex occurred with the intention of being faithful to that partner; when the relationship ended, however, one or both partners moving on to another relationship (Wright, 1994).

Contraception

As we will discuss in the following section, teen pregnancy is a significant issue. Proper use of contraception can prevent teen pregnancy. In looking at statistics, U.S. schools are providing information about contraception, although not on a widespread basis among

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13 teens. Three quarters of teen girls reported learning about birth control in school. Half of teen girls ages 15 to 18 discussed contraception with a health care provider, compared to 77% of young adult women (ages 19 to 24) (Kaiser Family Foundation, 2013). Many teens are not using contraception, especially at first intercourse (22% of teen females and 14% of teen males) (CDC, 2011b).

Teens who are using contraception are using a variety of methods as shown in the chart below:

Teen Pregnancy While adolescent pregnancy rates have declined, teen pregnancy still remains a significant problem. The CDC identified Teen pregnancy prevention as one of its top six priorities (McCracken & Loveless, 2014; Kearney & Levine, 2012). The U.S. teen pregnancy rate is one of the highest of all developing nations (Runzel, 2017). Teen pregnancy is something that affects young mothers and fathers, as well society as a whole, resulting in increased costs.

In 2008 (the most recent year for which national data are available), the pregnancy rate for U.S. teens aged 15-19 reached 67.8 per 1000 young women: its lowest point in more than 30 years, down 42 percent from its 1990 peak of 116.9 per thousand (Advocates for Youth). The abortion rate for U.S. teen females aged 15-19 in 2008 (the most recent year for which national data are available) was 14.3 per thousand females of that age, and this age group accounted for 16.2 percent of all abortions.

Furstenberg, Brooks-Gunn and Morgan (1989) studied adolescent mothers in later life. They found that up to 5 years after their pregnancies 49% had not graduated from high school and one-third were on Welfare. Many of these young mothers do recover from the initial problems, going on to graduate from high school and college. Some remain impoverished. The factors that played the most importance were that women whose parents were more educated tended to do better. Those women who were more successful prior to the pregnancy, such as being good students, tended to do better than those who were not.

Teen pregnancy also affects father. Fathers have a 25 to 30 percent lower probability of graduating from high school than teenage boys who are not fathers (Covington, Peters, Sabia, & Price, 2011). Teen fathers earn less over time than men who have children at an

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14 older age, are more likely to get involved with criminal behavior, including alcohol and drug abuse. There are few programs available to youth who become fathers, and this is an area of future opportunity (Runzel, 2017).

In reviewing the data on teen pregnancy, McCracken & Loveless (2014) recommend several steps in prevention. They that state that knowledge about, and access to contraception is important and that long-acting contraceptive methods have been shown to reduce teen pregnancy rates. They also suggest that pregnant teens could benefit from counseling on pregnancy options and counseling for reducing risk during pregnancy with regular prenatal care. Other recommendations are encouraging postpartum teens to breastfeed, monitoring them for depression, and providing access to reliable contraception to avoid repeat undesired pregnancy.

Kearney and Levine (2012) also studied reasons that the teen birth rate is so high, taking an economic perspective. Their research found that an important part of prevention is to provide young people from lower SES households with opportunities to become financially sustainable in order to decrease reliance on the welfare system and to decrease the perspective that having children is a path to financial sufficiency (which the research disproved).

Teen Dating Violence

One in ten high school students who dated or went out with someone within the previous 12 months reported having experienced dating violence. More than 10% of students reported experiencing physical violence, and 10% of students reported experiencing sexual dating violence. Seven percent of students have been physically forced to have sexual intercourse, with more females (11%) than males (4%) reporting this experience. One in four women ages 15 to 24 report that they have talked with a health care provider about dating violence (CDC, 2014).

Young women experience the highest rates of rape and sexual assault among all age groups. More than 1 in 5 (22%) college women have been victims of physical abuse, sexual abuse, or threats of physical violence. Among women who have ever been raped, 30% were raped when they were between the ages of 11 and 17 and 37% were raped between the ages of 18 and 24 (CDC, 2011).

Summary

Childhood and adolescence is a time of burgeoning sexuality. Each stage has it’s own developmental sexual milestones and challenges. Understanding of the biological and psychological aspects of sexuality informs increased understanding of children, adolescents and adults.

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Chapter 2 Topics in Human Sexuality: Sexuality Across the Lifespan Adulthood/Male and Female Sexuality

Introduction

The development of sexuality is a lifelong process that begins in infancy. As we move from infancy to adolescence and adolescence to adulthood, there are many sexual milestones. While adolescent sexuality is a time in which sexual maturation, interest and experience surge, adult sexuality continues to be a time of sexual unfolding. It is during this time that people consolidate their sexual orientation and enter into their first mature, and often long term, sexual relationships. This movement towards mature sexuality also has a number of gender- specific issues as males and females often experience sexuality differently. As people age, these differences are often marked. In addition to young and middle age adults, the elderly are often an overlooked group when it comes to discussion of sexuality. Sexuality, however, continues well into what are often considered the golden years.

Milestones in Adult Development

As in many cultures, the United States has various norms for sexuality. Adolescence is a time when teens try on many "sexual hats" in order to determine what is sexually pleasing. In the adolescent years, most adolescents are not engaging in partnered sexual behavior; solo masturbation is the most prevalent teenage sexual activity with rates as high at 43% of males and 37% of females (NSSHB, 2010). In early adulthood, people move toward mature, adult sexuality. Hyde and DeLamater (2013) term this a period of sexual unfolding, and include several factors in this process.

First is the development of sexual orientation. A 2014 report on sexual orientation and health among U.S. adults published by the Department of Health and Human Services (Ward et al., 2014) Among U.S. adults aged 18 and over, 97.7% identified as straight, 1.6% as gay or lesbian, and 0.7% as bisexual. These distributions differed by both sex and age. A higher percentage of women identified as bisexual, a finding consistent with other documented estimates of sexual orientation. With regard to age, a lower percentage of adults aged 65 and over identified as gay or lesbian (0.7%) or bisexual (0.2%) compared with adults aged 18–44 (gay or lesbian: 1.9%; bisexual: 1.1%) and adults aged 45-64 (gay or lesbian: 1.8%; bisexual: 0.4%). These estimates are similar to other surveys.

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The trend towards more mature sexuality can be seen in data from a 2010 Kinsey survey, which looked at sexual practices and partners. More than half the participants in the 2010 national sex survey ages 18-24 indicated that their most recent sexual partner was a casual or dating partner. For other age groups, the majority of study participants indicated that their most recent sexual partner was a relationship partner.

Another task of adult sexual development is learning sexual likes and dislikes and effectively communicating these to a partner (Hyde & DeLamater, 2013). This is often a process of sexual experimentation, and healthy communication positively impacts sexual connection and satisfaction.

Throughout the lifecycle, developmental milestones can affect sexuality. These milestones (sometimes referred to as “crises”) include:

1. Quarter-life crises: A quarter-life crisis typically occurs between the ages of 25 and 30. It often revolves around the challenges that arise from young adults newly living life on their own and feeling overwhelmed with new responsibilities; it can also happen after the birth of a child or if a person graduates from college and cannot find a job in their chosen field.

2. Mid-life crises: mid-life crisis include problems with work, trouble in a marriage, children growing up and leaving the home, or the aging or death of a person’s parents.

• a search for an undefined dream or goal • a deep sense of regret for goals not accomplished • a fear of humiliation among more successful colleagues • a desire to achieve a feeling of youthfulness

Sexuality Throughout the Lifecycle: Early Adulthood (approx 19-30)

Case Vignette

Maddie is a 19-year-old college student away from home for the first time. In high school she rarely went out, focusing instead on her grades. While she still wants to do well academically she is finding it difficult due to the number of opportunities she has to socialize. On her large college campus there are parties almost every night, and she has found herself involved in a number of casual hookups.

Young adulthood is a time when many begin to embark on sexual relationships while outside the confines of their childhood homes and away from the watchful eyes of parents. In the United States and Europe, most adolescents initiate sexual intercourse in their 17th year (Finer

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& Philbin, 2013). Parental monitoring has been linked to delayed sexual initiation and safer sexual practices (DiClemente, Crosby, & Salazar, 2006).

In early adulthood, most romantic relationships involve a sexual component. Among young adults ages 18 to 23 who are in any form of romantic relationship, only about 6% are not having sex of some sort (Regnerus, 2007).

Traditional dating has declined on college campuses, hookups—casual sexual encounters often initiated at social events in which alcohol flows freely—have become a primary form of intimate interaction (Bogle, 2008). Hamilton and Armstrong (2009) conducted a longitudinal study in which they followed several young women throughout college. These authors point to conflict that some young women experience: while they have been socialized to prefer relationships, college norms make this much more difficult (although those that are too sexually active may be labeled in a derogatory way, a sexual double-standard). There is some evidence to suggest that casual sex may affect mood; one study showed that men who engage in casual sex show few depressive symptoms, on average, while women with a history of such liaisons report the highest levels of depression (Grello et al., 2006).

Another societal change for young adults involves relationship patterns (both sexual and affectional). The median for marriage has risen to 26 for women and 28 for men. Many emerging adults are “trying on” sexual relationships for several years before “settling down” (serial monogamy). Young adults regularly move into and out of intimate relationships, but most are short-lived (Regnerus, 2007). Another trend is “friends with benefits,” the practice of having sex in a nonromantic relationship with a friend (Bisson & Levine, 2009) and increased acceptance of among young adults (Carroll et. al, 2008).

Sexuality Throughout the Lifecycle: Adulthood (approx 31-45)

Sexuality continues to develop into a person’s 30s and 40s. Patterns of serial monogamy are often replaced when people move into coupled relationships. These relationships are now characterized by increasing intimacy. Early writers on intimacy state that intimacy is conceptualized broadly as a process involving emotional and physical affection, closeness, cohesion, and sexuality (Waring, 1984). Intimacy results in partner closeness, friendship, and desire to share physical and emotional connections. Positive relationships with significant others in our adult years have been found to contribute to a state of wellbeing (Ryff & Singer, 2009).

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Most adults identify themselves through their relationships with family—particularly spouses, children, and parents (Markus et al., 2004). Having stable intimate relationships has also been found to contribute to well being throughout adulthood (Vaillant, 2002).

The model of relational development (M.L. Knapp) explains how people come together (and come apart). While this model spans many types of relationships, it also elucidates the sexual coming together couples experience.

Coming together consists of five phases—initiating, experimentation, intensifying, integration, and bonding.

1. During initiating, first impressions are made; physical factors play a large role in this phase. This phase may be more superficial as people are trying to make a good first impression.

2. During experimentation, the two people attempt to find some common ground between each other’s lives, such as common interests and hobbies. People start to open up more and ask more personal questions as they get to know one another.

3. During the intensifying phase, people open themselves up fully in the hope of being accepted by the potential mate. During this phase, people may reveal things about themselves or others in order to test the trust level of potential partners.

4. The integration phase involves people merging their lives together and solidifying a relationship status.

5. Finally, during the bonding phase, people recognize a commitment to one another (traditionally through marriage, though many alternative forms of commitment exist) and the relationship lasts until death, breakup, or divorce.

Singles, Marrieds and Cohabitators

During adulthood, peoples choose to enter into intimate or sexual relationships or to remain uncoupled. The U.S. government defines marriage as a social union or contract between people that creates kinship. Marital relationships involve many components: legal, social, spiritual, economic and sexual. The institution of marriage predates recorded history.

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The term never married refers to adults who have never been married. Thirty percent of Americans have never been married — the largest percentage in the past 60 years, according to the latest U.S. Census (2010). Among those ages 25 to 29, the never-marrieds increased from 27% in 1986 to 47% in 2009.

Given these statistics, it appears that most people in our society do eventually marry. Prior to making a marital commitment, many young adults engage in a pattern of serial monogamy, dating one exclusive partner, ending the relationship, then dating another. Males 30-44 report an average of 6-8 female sexual partners in their lifetime, while females 30-44 report an average of 4 male sexual partners in their lifetime. 56% of American men and 30% of American women have had 5 or more sex partners in their lifetime (Mosher, Chandra, & Jones, 2005).

There has been some change in dating patterns with the surge of Internet dating sites. This has vastly expanded the dating pool, which previously had included couples meeting through the introductions of family and friends and through institutions such as church and school.

In early adulthood, it is common for couples to experiment with commitment at varying degrees, such as from an exclusive dating relationship to living together. Cohabitation refers to an arrangement whereby two people decide to live together on a long-term basis in an emotionally or sexually intimate relationship. From a sexuality perspective, it is interesting that cohabitation is a public declaration of a sexual relationship (Hyde & DeLamater, 2013). Cohabitation has become more common, and is sometimes an end to itself and not a precursor to marriage. About Cohabitation has often been characterized as a trial marriage and about 40% lead to marriage within two years and about 60% eventually culminate in marriage between the cohabiting partners.

Cohabitators do appear to engage in sexual behavior with more frequency than married persons. A sample of 7,000 adults found that married couples had sexual intercourse 8 to 11 times per month while those who lived together engaged in sexual intercourse 11 to 13 times per month (Call et al., 1995).

Sex and the Married Couple

Case Vignette

Kevin and Marie, ages 28 and 26 respectively, have been married for 7 years and are seeking marital counseling. In assessing their degree of intimacy, Dr. Janey found that a frequent source of conflict between the couple was what Kevin viewed as a rejection. The couple reported engaging in sexual intercourse approximately once a week; Kevin, however, felt that anything

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20 less that 2-3 times per week was insufficient and a cause of the other problems in the marriage. How much is “normal,” asks Kevin.

Questions such as this are a frequent source of discussion in marital as well as individual counseling. Although it is difficult to identify a norm, it appears that engagement in sexual intercourse is mediated by age (see chart below). As would be expected, frequency declines as both men and women get older. The explanation for this is both biological, such as decrease in vaginal lubrication and poor health, and psychological, habituation to sex with the same partner. As with the case vignette, research has found that sexual inactivity has been associated with unhappiness in the marriage (Donnelly, 1993; Huston et al., 1996). Sexual dissatisfaction is associated with increased risk of divorce and relationship dissolution. (Karney, 1995).

A large-scale study by Donnelly (1993) analyzed marital sexuality. Donnelly interviewed 6,029 married people to determine which factors are related to sexually inactive marriages and if sexually inactive marriages are less happy and satisfying than those with sexual activity. Donnelly measured nineteen independent variables including: life satisfaction, religious fundamentalism, gender role traditionality, individualism, marital interaction variables, and marital happiness. She found that the lower the marital happiness and shared activity, the greater the chance of sexual inactivity and separation. Sexual inactivity was found to be associated with old age, the presence of small children, poor health, and in males, duration of marriage. Sexually inactive marriages are not happy, therefore, are not satisfying marriages.

Another study of married couples found age and marital satisfaction to be the two variables most associated with amount of sex. As couples age, they engage in sex less frequently with half of couples age 65-75 still engaging in sex, but less than one fourth of couples over 75 still sexually active. Across all ages couples that reported higher levels of marital satisfaction also reported higher frequencies of sex. (Call, 1995).

The results of a large-scale study of married men and women is reported below.

Kinsey Institute (NSSHB, 2010)

Percentage of Married Men Reporting Frequency of Vaginal Sex, N=2396 Age Group

18-24 25-29 30-39 40-49 50-59 60-69 70+

Not in past year 4.2 1.6 4.5 9.1 20.6 33.9 54.2

A few times per year 12.5 9.3 15.6 16.2 25.0 21.2 24.2

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to monthly

A few times per 30.0 36.4 32.5 24.1 31.8 20.5 63.2 month to weekly

2-3 times per week 26.0 27.1 39.0 25.3 18.8 38.6 0.0

4 or more times per 10.0 6.3 6.5 11.5 4.7 2.3 0.0 week

Percentage of Married Women Reporting Frequency of Vaginal Sex, N=2393 Age Group

18-24 25-29 30-39 40-49 50-59 60-69 70+

Not in past year 11.8 3.5 6.5 8.1 22.0 37.0 53.5

A few times per year 14.7 11.6 16.3 21.7 23.7 20.0 25.4 to monthly

A few times per 14.7 47.7 50.2 46.6 36.2 35.9 18.3 month to weekly

2-3 times per week 35.3 35.2 21.9 20.8 16.9 6.2 1.4

4 or more times per 23.5 2.0 5.1 2.7 1.1 0.0 1.4 week

Marital and Partnered Sexuality

The chart above describes the frequency of vaginal sexual intercourse. According to the National Survey of Sexual Health and Behavior (NSSHB), there is much variability in the sexual repertoires of U.S. adults, with more than 40 combinations of sexual activity described at adults’ most recent sexual contact. It is rare that adult men and women engage in just one sex act when they have sex. While vaginal intercourse is still the most common sexual behavior reported by adults, many sexual events do not involve intercourse and include only partnered masturbation or oral sex (NSSHB, 2010). Determining what marital sexuality will be like has sometimes been described as a “mating dance,” or as the process of “negotiating sex.”

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Sexual Practices

So what is “having sex”? In a recent study at The Kinsey Institute, nearly 45% of participants considered performing manual-genital stimulation to be “having sex,” 71% considered performing oral sex to be “sex,” 80.8% for anal-genital intercourse. Considerations of “sex” also varied depending on whether or not a condom was used, female or male orgasm, and if the respondent was performing or receiving the stimulation (NSSHB, 2010).

One sexual behavior that is often considered to be more taboo is anal intercourse. Part of the taboo concerns the perception that anal sex is generally a homosexual act. Anal sex commonly refers to the sex act involving insertion of the into the anus of a sexual partner. The term can also include other sexual acts involving the anus, analingus (anal–oral sex). Anal sex it is not rare, although it is reported by fewer women than other partnered sex behavior. Partnered women in the age groups between 18-49 are significantly more likely to report having anal sex (NSSHB, 2010).

Masturbation

While many people think that the trend to mature sexuality means that masturbation is unusual in adulthood, this is not the case. Many people masturbate, even while they are married and have access to partnered sex. This behavior is normal, but can sometimes be kept secret due to feelings of guilt. According to one study of the masturbation habits of men and women, nearly 85% of men and 45% of women who were living with a sexual partner reported masturbating by themselves in the past year (Laumann, Gagnon, Michael, Michaels, 1994). Masturbation, then, appears to be a healthy sexual outlet.

Within relationships, another pattern involves partnered or mutual masturbation. Mutual masturbation is a sexual act where two or more people stimulate themselves or one another sexually, usually with the hands. Across all age groups, partnered women are significantly more likely to report having engaged in partnered masturbation as compared to nonpartnered women (NSSHB, 2010).

Changes in Sexual Patterns

Case Vignette

Sarah and John are presenting for counseling. John feels like his whole world his turned upside down following the birth of his son, who is now 8 months old. “Sarah and I used to be so close,

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23 and had a great sex life,” he says. “Since the baby has been born we’ve had sex a total of one time. She’s just not interested.” While Sarah recognizes John’s feelings, she responds that she is just “too tired” all the time and has had difficulty balancing the demands of work and a new baby.

Within marriage and partnerships, there are changes in sexual patterns. There is often a decrease in the number of sexual encounters due to habituation ¾ couples becoming accustomed to one another sexually, which results in decreased interest in sex.

Pregnancy

Another time in which there is much change in sexual patterns is following a pregnancy. These changes are at least initially motivated by physical parameters, but may also be psychological.

For married couples, the first child is often born within the first five years of marriage, which is also a period that has been shown to hold the highest risk for divorce (Bramlett & Mosher, 2001). Cowan and Cowan, who are some of the earliest authors to look at new parenthood and marital intimacy state: “we can conclude with some confidence that the transition to parenthood constitutes a period of stressful and sometimes maladaptive change for a significant proportion of new parents” (1995, p. 412).

Several authors have looked at pregnancy and sexual function. Yenial and Petri (2014) conducted a comprehensive review on pregnancy, childbirth and sexual functioning. They found that sexual function decreases throughout pregnancy. The literature studied pointed to decreasing desire and orgasm, increasing pain and other sexual dysfunction problems in the first 3 months gradually improved within 6 months after delivery. This process is affected by many factors such as socio-cultural, age, parity, breastfeeding, depression, tiredness, sexual inactivity during the first trimester, postpartum body image, worries about getting pregnant again, and urinary tract infections. Serati et al. (2010) had similar conclusions about this time period, pointing to a significant decline during pregnancy, particularly in the third trimester and that persisted for 3-6 months following delivery. Breast-feeding, dyspareunia, and postpartum pelvic floor dysfunction were reported as possible causes for the delay in resuming sexual intercourses after childbirth.

After pregnancy, sexual contact is often delayed for several weeks or months, and may be difficult or painful for women. Injury to the perineum or episiotomy are common reasons, as is vaginal dryness may occur following giving birth for about three months due to hormonal changes. Women who breast-feed are more likely to report painful sex and reduced libido, both due to hormonal changes such as a reduction in levels of estrogen. A water-soluble lubricant, such as K-Y jelly or AstroGlide, may be helpful in reducing dryness and discomfort. Although sexual activity other than intercourse is possible sooner, some women experience a prolonged loss of sexual desire after giving birth. Although this is not uncommon, it is always advisable to consult with a physician.

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Parenthood

While the articles described above looked primarily at the physiological aspects of sexual functioning in the and beyond and how the experience of parenthood affects sexuality and intimacy. While the changes in intimacy span a range of areas, overall scores of marital satisfaction in the postpartum period (up to 18 months following birth) suggest that this may be a time of more marital distance, including sexual distance (Gottman et al., 2002).

Many researchers have looked at early parenthood and marital satisfaction. Studies have shown declines in marital satisfaction immediately following birth (e.g., Gottman et al., 2002). Researchers have looks at a number of positive relationship factors including relationship-focused leisure time (needed for sex) and social support (Simpson et al., 2003).

Doss (2009) suggests that a way to understand changes in post-birth relationship functioning is by using the conceptual framework of the Vulnerability-Stress-Adaptation (VSA) model (Karney & Bradbury, 1995). In this model, changes in relationship quality are understood to be a function of three interrelated constructs: enduring vulnerabilities, stressful events, and adaptive processes. Enduring vulnerabilities of the individual and the couple (e.g., limited education) increase chances of experiencing events as stressful and adapting poorly. Additionally, one could consider that while couples experience the same potentially stressful event (birth of their baby), the nature of that stressful event can vary substantially between couples. For example, the timing of the birth and the gender of the baby could alter the impact of the first baby on relationship functioning. Finally, couples have different levels of adaptive processes (e.g., communication, commitment) to help them cope with the stresses placed on their relationship functioning after birth. In looking at these factors we can better understand how some couples experience dissatisfaction and disruptions in relationship quality/sexual functioning while others may not.

Infidelity

Case Vignette

Joslyn and Eric have been married for 8 years. Joslyn has recently noticed that Eric has become more distant. She was shocked to find that he had been exchanging text messages with a female co-worker. Although Eric denies that the relationship was in any way physical, Joslyn feels angry and hurt. She expresses uncertainty that she will be able to move past her feelings of betrayal.

Within intimate, partnered, and marital relationships, there is generally a belief in the exclusivity of the relationship, particularly sexual exclusivity. Infidelity is a breach of this expectation. Infidelity tests relationships and results in feelings of betrayal and mistrust. In our culture there is also a strong prohibition against infidelity, which includes both sexual breaches

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25 and emotional unfaithfulness. Smith (1994) surveyed Americans about infidelity and found that 90% of the general public agree that it is “always” or “almost always” wrong for a married person to engage in extramarital sex. The prohibition against infidelity also extends across cultures. Betzig (1989), for example, found Infidelity to be the most cited cause of divorce in over 150 cultures. Within the counseling relationship, many couples seeking counseling are presenting due to one partner’s unfaithfulness.

How common is infidelity? Two studies of extramarital sex found similar statistics: approximately 20-25% of men and 10-15% of women engage in extramarital sex at least once during their marriage (Laumann, 1994; Wiederman, 1997). These studies did not include a sampling of cohabitating individuals. Treas and Giesen (2000) looked at infidelity among couples that are married or living together in a partnered relationship. The researchers found that 11% of adults who have ever been married or cohabited have been unfaithful to their partner (Treas & Giesen, 2000).

The faces of infidelity

There is some variability in what is considered infidelity. Certainly, sexual contact outside of a marital or partnered relationship is considered infidelity (except, of course, if the couple has the understanding that that is acceptable to both of them, such as in the case of an “open” marriage). There is less consensus, however, about other things that may be considered infidelity.

One such argument involves the idea of emotional infidelity ¾ emotional involvement with another person, which leads to the channeling of emotional resources, such as time and attention, to someone else.

Another area that leads to disagreement is the use by one partner of pornography. This has become a particular concern in the age of the Internet. In a recent national study of Internet pornography, 14% of people reported having used a sexually explicit website ever, men more so than women. 25% of men reported visiting a pornographic site in the previous 30 days; 4% of women reported visiting pornographic sites in the same timeframe. (Buzzell, 2005). Additionally Mitchell et al. (2005) found that overuse, pornography, infidelity, and risky behaviors are among the most frequently treated Internet-related problems by mental health professionals. Although these areas are ones that merit further study, such statistics cannot be ignored.

Factors that contribute to infidelity

Infidelity is influenced by many social and demographic factors. (Treas & Giesen, 2000) looked at these factors in a recent study. These researchers attempted to determine why some people are sexually exclusive while others have sex with someone besides their mate. Previous research had linked personal values, sexual opportunities, and quality of the marital

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26 relationship to extramartial sex. Treas and Giesen (2000) conducted a national survey of married and cohabitating couples. The researchers found that there is a higher likelihood of sexual infidelity among those with stronger sexual interests, more permissive sexual values, lower subjective satisfaction with their union, weaker network ties to partner, and greater sexual opportunities. Infidelity was also associated with having been part of a couple for a long time; having had a high number of prior sex partners and being male.

Midlife

Case Vignette

Julia, age 53 and Carl, 56, have been married for 15 years. A second marriage for them both, and they have felt very close. While they had a robust sexual life in the early years of their marriage, they have noticed that neither one desires sex as much as they once did. Much of the reason concerns physiological changes. Julia is especially self-conscious about her higher weight, and Carl about his inability to achieve at

Midlife is a time of change, sexual and otherwise. Midlife spans the ages of approximately 40- 65, although there is great variability. At midlife, adults experience age-related changes based on many factors: primary aging (based on biological factors including physical and hormonal changes), and secondary factors (aging that occurs due to controllable factors, such as lack of physical exercise or poor diet.) In early adulthood (ages 20–40 physical abilities are at their peak. Aging speeds in midlife with multiple physical changes, cosmetic and otherwise. The skin becomes drier and wrinkles start to appear by the end of early adulthood.

The two hormones that most affect sexual physiology, estrogen and testosterone, tend to decrease during midlife, in both women and men. Women experience a gradual decline in as they approach the onset of —the end of the —around 50 years old. Menopause results in the shifting hormone levels, resulting in a range of symptoms, such as mood swings, and less interest in sexual activity. Men, on the other hand, can continue to father children until late in life, many middle-aged men experience a decline in fertility and in frequency of orgasm.

As these hormone levels decline, people commonly see symptoms such as decreased libido and changes in sexual response. But this is just the tip of the iceberg. At this time, there are also life changes, such as changes in roles relationships. Some examples include: becoming “empty nesters” after years of child-rearing, reaching career goals, transitioning to role of grandparent or caring for an aging parent. The loss of active parent role when children move out of the home is often accompanied by newfound gains in marital satisfaction and opportunities for exploring new interests, growth, and fulfillment (Ryff & Seltzer 1996).

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Sexuality

According to Mitchell (2012) there are four primary components that influence sexuality in midlife. These are:

1. Self-perception. At midlife, it is common to experience changes in weight, fitness, appearance and mood causing people to feel less desirable and therefore less interested in sex. Some theorists also point to the "double standard of aging" causes women to seem less desirable as they lose their youthful appearance. For both men and women, anxiety about getting older is heightened in a society that places a premium on youth. This is also a time when adults are first diagnosed with chronic physical illnesses such as hypertension.

2. Gender role changes. Women at midlife often experience shifts in their priorities, beginning to focus on their own needs and self care, as well as creative endeavors. They often have a change in career and focus. Men are more likely to slow down at work and are looking to balance their lives with more leisure. This impacts behaviors, including sexual behaviors, and can require negotiation of the relationship.

3. Sexual desire. Loss of libido is common in women as they go through perimenopause into menopause. Men may have a decreased libido as well, as their testosterone slowly wanes.

4. Sexual response: Women often describe slow arousal and difficulty with orgasm. A large proportion of middle-aged men experience erectile dysfunction. Sexual dysfunction can have physical causes but also may be related to health, lifestyle, and emotional well being.

Research on Sexuality at Midlife

What does the research say? Thomas et al. (2017) looked at sexuality among women in midlife, finding that there are positive and negative changes. The most common negative changes were decreased frequency of sex, low libido, vaginal dryness, and anorgasmia. Participants attributed negative changes to menopause, partner issues, and stress. Most participants responded to negative changes with adaptation, including changing sexual behavior and prioritizing different aspects of sex. Participants also reported positive changes, attributed to higher self-confidence, increased self-knowledge, and better communication skills with aging. Changes in midlife and older age, will be discussed in more detail later in this material.

Sexuality in Older Adults

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Case Vignette Benjamin, age 74, and Jeanette, age 66, have been married for 47 years. They have weathered many challenges during this time, but are now really struggling. Their sex life, which had been mutually satisfying, has deteriorated due to Benjamin’s impotence. Although Jeanette has been patient, she is upset that her proud husband will not tell him doctor about the problem.

Sexuality occurs across the lifespan. Although there is some decline in the frequency of sexual contact as men and women age, many older men and women continue to be sexual (see the chart below). Many of the issues previously discussed, such as sexual communication issues and relational problems, apply to aging people. There are, however, specific, aging related issues that require some adaptation. While these do not apply to all older adults, it is helpful to understand some of the physical and psychological changes associated with aging.

Kinsey Institute Frequency of Sexual Intercourse

Frequency Men 50-80+ Women 50-80+

Not in past year 46.4 58.0

A few times per year 17.8 13.5

2 or 3 times per week 24.6 20.3

A few times per month 10.2 6.8

4 or more times per week 0.9 1.4

The current population of older adults is one of the most highly educated and financially sound groups in history. It is also a very active group: nearly half of all Americans age 55 and over volunteered at least once in the past year. Even among those age 75 and older, 43 percent had volunteered at some point in the previous year. Older Americans no longer see retirement as an “endless vacation,” but increasingly as an active, engaged phase of life that includes work and public service (Fact Sheet on Aging, Experience Corps, n.d).

Although this is clearly a vibrant group of men and women, there are certain aspects of aging that can negatively affect sexual interest, activity and satisfaction. Among these factors are

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29 losses, changes in body image, changed living arrangements and physical changes associated with aging.

Psychological Changes

Societal Prohibitions against Sexuality/Reactions to Aging

Ageism extends to our beliefs about sexuality. Older adults are often indirectly told that sexuality is for the young. Images in the media equate sexuality with youth. Sexual attractiveness, then, is often connected with the young. For women in particular there is a sexual double standard. Men are often thought to maintain their sexual activity, while older women are not. Sexually appealing women are depicted as young, and the importance of maintaining youth is supported by cosmetics that hide gray hair, wrinkles, etc. Women then are more prone to developing concerns about the physical aspects of aging, such as drooping breasts, weight gain, etc. There has been a rise in the number of late stage eating disorders, and these body image issues play a role in the increase. Body image, of course, affects sexuality (Crooks & Baur, 2000).

Loss of a Partner

Loss of a partner is a life crisis that many men and women will face over the course of their lifetime. Although people react to this crisis in many ways, some eschewing further relationships and some open to them. Women statistically have a longer life expectancy than men. More men than women, however, go on to remarry. One problem sometimes seen in this situation is the aptly named “widowers syndrome” in which a man can become sexually aroused by a new partner but cannot maintain an erection (Rossi, 1999) and which is often a result of survivor’s guilt. Women can experience the same problem.

Changes in Living Environment

With increasing medical needs, many elderly people need to enter nursing homes or assisted living facilities. These environments often fail to address the sexual needs of older men and women. There may be restrictions on behavior or the inability to live with a spouse or partner. There are sometimes similar issues when an aging parent goes to live with a child. These issues need to be considered in making choices about living situations.

Physical Changes

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There are many physical changes associated with healthy aging, which are described below. Additionally there are illnesses that may limit a person's ability to relate sexually.

Physical Changes in Women (Zeiss & Kasi-Godley, 2001)

• Reduced levels of hormones (estrogen, progesterone, androgen)

• Thinning of vaginal walls

• Decreased vaginal lubrication

• Changes in the , making penetration more difficult

• Reduction in vaginal contractions

Physical Changes in Men (Zeiss & Kasi-Godley, 2001)

• Reduced levels of hormones (tester one)

• Decreased firmness during erections

• Reduction in amount of ejaculate

• Longer refractory period

• Need for more direct stimulation to support erection

Research

Kalra et al. (2011) looked at sexuality in the elderly. They studied a group of participants to look at sexual function and activity in older age. The researchers found that in the group they studied 72% individuals below 60 were sexually active, while only 57% above 60 were active. Others had become completely abstinent at some time in their lives. Many people in the sample had chronic illnesses including diabetes, hypertension and arthritis. As high as 70% subjects perceived that their age negatively affected their sexuality, although expressed that the desire was still there. For those that reported lack of sexual activity, people reported various reasons for this including: men reported sexual inactivity because of lack of desire, ill health, or erectile dysfunction in their old age, whereas women reported sexual inactivity due to loss of partner. All of those surveyed agreed that they took significantly more time for compared to before. There was also a noted decrease in sexual satisfaction.

One area that had generally not decreased (and in some cases increased) was intimacy). 48% subjects did not perceive any change in the areas of love and intimacy in their relationship over the years, while these areas had improved in 25% of the subjects’ lives.

Summary

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Sexuality continues throughout the lifecycle, and physical and emotional intimacy are connected. It is important for mental heath professionals to be aware of the developmental changes that may affect adult sexuality, and to be nonjudgmental in approaching client needs with regard to enhanced sexuality in early, middle and later adulthood.

Chapter 3 Topics in Human Sexuality: Physical and Emotional Aspects of Puberty

Introduction

Adolescence is a time of profound development and maturation, physically, cognitively and socially. Foremost are the biological changes of puberty, a complex series of biological transitions. Puberty generally occurs at about age 10-14 in girls and between 12-16 in boys. Puberty is a time of rapid growth. The most evident physical changes involve increases in height and the development of secondary sex characteristics. Biologic changes of puberty also include alterations in body composition and the achievement of fertility. During puberty there are changes in most body systems (neuroendocrine axis, bone size, and the cardiovascular system). A number of factors play a role in the onset of puberty, including genetic and environmental factors, as well as body fat and/or body composition. Puberty may also be accompanied by emotional and mood changes.

Cognitive maturation encompasses the development of formal operational thought, psychosocial maturation involves progression through the stages of adolescence), and biological maturity involves the physical process of puberty.

For females, a key physical change that is part of the puberty process involves sexual maturation. In girls, the physical process of is a key biological event and marker of puberty. It is more complex than just the physiology. Menstruation, the culmination of the monthly cycle in which the body prepares itself for a possible pregnancy is also the start of womanhood and of female sexuality. Many cultures celebrate the first with a moon ritual in which the newly menstruating young woman is joined by important females in her life to mark her entry into womanhood and to celebrate menarche.

Males also go through the physical and emotional transformations of puberty and these are as profound as the process of menstruation. Maturational changes of puberty include alterations in appearance (such as growth and muscularity), sexual maturation (and sexual development), hair growth, voice changes and emotional changes.

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Understanding the biological and psychological aspects of puberty will allow mental health professionals to have a deeper understanding of human sexuality.

Defining Puberty in Females

Physical Aspects of Puberty

Puberty is the physical process of sexual maturation; the most visible changes during puberty are growth in stature and development of secondary sexual characteristics. The term puberty is derived from the Latin word puberatum (age of maturity) and refers to the bodily changes of sexuality. In girls, puberty usually begins at 11 years of age, but may start as early as age 7. A recent study published in Pediatrics found that by age 7, about 10 percent of white and 23 percent of African-American girls had started developing breasts. A study published in 1997 found that by age 7, only 5 percent of white females and 15 percent of black females had reached puberty. Puberty, then, is occurring earlier.

Puberty is initiated by hormone signals from the brain to the ovaries. Puberty starts when the pituitary gland begins to produce two hormones , luteinizing hormone (or LH) and follicle-stimulating hormone (or FSH), which cause the ovaries to enlarge and begin producing estrogens.

The first sign of puberty in girls is . As growth of the breasts continues, females develop contours of the hips and buttocks, distinguishing them from their male counterparts. Growth of begins shortly after breast development, followed two years later by underarm hair growth. There is some variability in this process, such as some young women developing breasts but showing no other signs of sexual maturation. The first menstrual cycle generally begins about 2-3 years after breast development.

Girls also generally experience a growth spurt during the ages of 9.5 to 14.5. This growth gradually slows as estrogen levels increase.

In addition to changes in body composition and the achievement of fertility, adolescence is a time of changes in most body systems in both male and females, such as the neuroendocrine axis, bone size, and mineralization; and the cardiovascular system. Cardiovascular changes and blood pressure changes also occur during puberty. Anxiety sensitivity refers to the fear of behaviors or sensations associated with the experience of

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33 anxiety. The biological changes of puberty may lead to anxiety sensitivity. Akça et al. (2015) studied anxiety sensitivity in a sample of 133 healthy adolescents (70 boys, 63 girls) aged 10–17 years. The researchers determine puberty (Tanner) stage, pulse rate, and blood pressure of each participant were determined. Pubertal growth and blood pressure were found to interact with anxiety sensitivity during adolescence.

Measuring Stages of Puberty

Puberty consists of a series of events and a sequence of changes in secondary sexual characteristics. The Tanner Scale is a scale of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts (ranging from prepubital to mature adult breasts), genitals and development of pubic hair (no hair, sparse growth, adult in type and quantity).

Tanner Stages (James M. Tanner, 1969) – Girls Sexual Maturity Rating

Breast Development

Stage 1: Prepubertal Stage 2: Breast bud stage with elevation of breast and papilla; enlargement of Stage 3: Further enlargement of breast and areola; no separation of their contour Stage 4: Areola and papilla form a secondary mound above level of breast Stage 5: Mature stage: projection of papilla only, related to recession of areola

Pubic Hair

Stage 1: Prepubertal (can see velus hair similar to abdominal wall) Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled along labia Stage 3: Darker, coarser and more curled hair, spreading sparsely over junction of pubes

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Stage 4: Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs Stage 5: Adult in type and quantity, with horizontal distribution ("feminine")

Growth

Stage 1: 5-6cm/year Stage 2: 7-8cm/year Stage 3: 8cm/year Stage 4: 7cm/year Stage 5: No further height after 16 year

Precocious Puberty

Precocious (early) puberty is defined as puberty that occurs before age 7-8. While puberty is largely a biological event, there are also social and psychological domains involved. is a common problem affecting up to 29 per 100,000 girls per year (Fuqua, 2013). In girls, this is signaled by the growth of breasts and pubic hair. In many cases, there is no identifiable cause for precocious puberty, and it may be considered a variation of normal puberty. It is always best to consult with a physician, however, because early puberty can be caused by medical conditions such as adrenal gland abnormalities or ovarian abnormalities or an abnormality of the master (pituitary) gland; this is called central precocious puberty, or CPP. Doctors will determine the presence of CPP through blood tests, to check the pituitary hormones (luteinizing hormone, or LH, and follicle- stimulating hormone, or FSH) and levels of estradiol or testosterone).

In rarer instances the ovaries can start working on their own sooner than normal. This is known as peripheral precocious puberty or PPP.

Reasons for Precocious Puberty

There are a number of other possible causes of precocious puberty. In both boys and girls, the adrenal glands may start producing weak male hormones, called adrenal androgens, at

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35 an early age (such as age 8). This can cause the development of pubic hair and body odor. In most cases, no medical treatment is needed. Another possible cause of precocious puberty is exposure to estrogen- or androgen-containing creams or medication, either prescribed or over-the-counter supplements (Kaplowitz & Silverman, 2014).

While precocious puberty can be connected to any of the above factors, for females, the most likely factor determining age of menarche is percentage of body fat (Bubach, Menezes, Barros et al., 2016). In other words, the percentage of body weight that is fat (such as breast tissue) must rise for menstruation to occur.

Psychological Effects of Precocious Puberty

Precocious puberty has psychological effects. As physical appearance becomes more mature and “adult,” girls and boys are faced with navigating changing social norms and expectations. These changing norms and expectations may result in the need to revisit and expand identity and self-perception (Mendle, Turkheimer & Emery, 2010). Maturational timing, both early and late, increases risk for emotional and behavioral problems during adolescence and early adulthood.

Girls who start puberty may experience concerns in a number of realms. From a biological perspective hormonal shifts may result in increased arousal and irritability (Dahl, 2004). Neurological changes can also increase propensity for risk-taking and sensation-seeking early in adolescence; the development of judgment and self-regulatory skills to master these impulses only develops towards the end of maturation.

Premature maturation also influences how girls view their bodies. Early maturers tend to view their bodies negatively, perhaps due to size differences between them and same age peers (girls who had gone through puberty early tend to be bigger than peers and feel societal pressures for thinness). Early developers are often less satisfied with their bodies and are more likely to care about how they look. These girls stand out in comparison to friends and this may result in low self esteem (Choi & Kim, 2016). Pubertal timing also has effects on body image in males (Leone, Wise, & Mullin, 2015).

There is also evidence that girls who reach puberty early may be rejected by peers, and may seek older and more mature friends, which can lead to premature experiences, particularly within the sexual realm. These young women may not have had enough time to complete the necessary childhood developmental tasks before entering the world of the older crowd. They have had less time to form a sense of self, which could lead to poor decision-making (Mrung, Elliot, Davies et al., 2014). Results of a large-scale cohort study

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(n=8055 participants) suggests that early puberty in girls may increase the risk of depression (Galvao, Silva, Zimmermann et al., 2014).

Delayed Puberty

Delayed puberty is usually defined as puberty that occurs later than the norm. If a young woman does not develop breast tissue by age 13-14 or does not begin to menstruate by 5 years after breast development, puberty is considered delayed. There are a number of reasons for delayed puberty in girls. Some girls with delayed puberty are simply late maturers, but once puberty begins, it progresses normally. This situation is called constitutional delayed puberty. Constitutional delayed puberty is more common in boys than girls, and may be due to genetics. Constitutional delayed puberty is more likely to occur if the mother started her periods after age 14 or if the father attained puberty at an older age (American Academy of Pediatrics and Pediatric Endocrine Society, 2014).

Body fat also explains why girls with anorexia, other forms of excessive dieting, and those that engage in extreme exercise may not menstruate within the norm or why there may be a cessation in menstruation. This is also seen in girls who are very athletic, such as dancers, gymnasts or swimmers. Chronic physical illnesses in which lead to decreased body fat also may result in delayed puberty.

Kapczuk (2017) researched elite athletes and pubertal delay, looking at the interconnections between pubertal timing (early or late) and it’s impact on an athlete selection for a particular sport. Kupczuk identifies several factors that affect pubertal timing including genetic predisposition, training load, nutritional status (including negative energy balance from calories in versus expended) and psychological stress. This author draws several conclusions, including the recommendation that female athletes who do not begin secondary sexual development by the age of 14 or menstruation by the age of 16 warrant a comprehensive evaluation and targeted treatment.

Another cause of delayed puberty is a medical condition known as primary ovarian insufficiency, which results in the ovaries not developing properly. One major cause of primary ovarian insufficiency is Turner Syndrome, in which girls with this condition are missing one of the two X chromosomes. Primary ovarian insufficiency may also result from damage to the ovaries, such as that resulting from radiation and cancer treatment. This can also be caused by the body’s own immune system (Kaplowitz, 2014).

When there is suspicion of delayed puberty, the primary doctor or endocrinologist will generally order blood tests to measure levels of LH, FSH, and estradiol. High levels of LH

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37 and FSH indicate that the ovaries are not working properly, and the pituitary is trying to stimulate them to work harder. If the cause of the ovarian insufficiency is unclear, additional studies are generally ordered. Treatment of delayed puberty varies based on the cause.

The psychological effects of delayed puberty are not as widely researched as those of precocious puberty. Girls experiencing delayed puberty may report psychological distress or pressure of not developing like others. More concrete research is needed to assess ways in which delayed puberty effects teens.

Menarche

At about ages 12-13 menarche, first menstruation begins. Menstruation is the shedding of the lining of the uterus (endometrium) accompanied by bleeding. Menstruation occurs in monthly cycles throughout a woman's reproductive life. Menstruation starts during puberty and stops permanently at menopause.

Women cannot actually become pregnant until about two years after menarche.

The menstrual cycle is regulated by hormones. Luteinizing hormone and follicle- stimulating hormone are produced by the pituitary gland and promote and stimulate the ovaries to produce estrogen and progesterone. Estrogen and progesterone stimulate the uterus and breasts to prepare for possible fertilization.

Menarche is an important biological event but also an important psychological one. Girls display a range of reactions to menarche, which range from acceptance and pride to shame and disgust. The most negative reactions occur in girls who have not been prepared for menarche.

Phases of Menstruation

The menstrual cycle begins with the first day of bleeding, which is counted as day 1. The cycle ends just before the next menstrual period. Menstrual cycles normally range from about 25 to 36 days. Only 10 to 15% of women have cycles that are exactly 28 days long. Usually, cycles vary the most and the intervals between periods are longest in the years

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38 immediately after menarche and before menopause. Menstrual bleeding lasts 3 to 7 days, averaging 5 days.

The menstrual cycle has three distinct phases. These are:

Follicular Phase: This phase begins on the first day of the menstrual cycle. The primary process that occurs in the is the development of follicles in the ovaries.

At the beginning of the follicular phase, the lining of the uterus is thick with nutrients that are intended to nourish an embryo. If no has been fertilized, estrogen and progesterone levels are low. The top layers of the uterus is shed, and menstrual bleeding occurs. The follicular phase lasts about 13 or 14 days. This phase ends when the level of luteinizing hormone surges. The surge results in release of the egg.

Ovulatory Phase: This phase begins when the level of luteinizing hormone surges. Luteinizing hormone stimulates the dominant follicle to bulge from the surface of the ovary and finally rupture, releasing the egg. The ovulatory phase usually lasts 16 to 32 hours. It ends when the egg is released.

Luteal Phase: This phase begins after ovulation. It lasts about 14 days (unless fertilization occurs) and ends just before a menstrual period. In this phase, the ruptured follicle closes after releasing the egg and forms a structure called a corpus luteum, which produces increasing quantities of progesterone. If the egg is not fertilized, the corpus luteum degenerates after 14 days, and a new menstrual cycle begins.

Managing Menstruation

Effective, hygienic management of menstruation is essential for women and girls to participate in society with dignity and comfort (Hennegan & Montgomery, 2016). An issue that clinicians do not always consider is menstrual hygiene management. Methods for managing monthly menstrual cycles include:

• Sanitary Napkins or pads - rectangles of absorbent material that attach to undergarments to absorb menstrual flow after it leaves the body. These are the most commonly used method with teens and young women for have just started menstruating. It’s best to change pads frequently, at least every 3 hours, to prevent buildup of bacteria and eliminate odors

• Tampons – more commonly used by older teens, athletes, these absorb menstrual flow internally. Tampons are made of absorbent material, but compressed into a tubular shape. Tampon needs to be changed every 4 to 6 hours or when they are

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saturated with blood. They have been associated with Toxic Shock Syndrome (discussed below), so proper hygiene and management are critical.

• Menstrual Cups - Like a tampon, a menstrual cup is inserted into the vagina. Instead of absorbing blood, though, the cup catches it before it flows out of the vagina. Menstrual cups are made of flexible materials, like rubber or silicone. Disposable cups should be changed several times a day. It is important to educate young women that menstrual cups are not an effective source of birth control.

Toxic Shock Syndrome

Toxic shock syndrome is a life-threatening bacterial infection that has been associated with the use of tampons. Toxic shock syndrome results from toxins produced by Staphylococcus aureus (staph) bacteria, but the condition may also be caused by toxins produced by group A streptococcus (strep) bacteria. Symptoms of toxic shock syndrome develop suddenly, and the disease can be fatal.

Researchers don't know exactly how tampons cause toxic shock syndrome. It may be that when tampons are left in place for a long time, they become a breeding ground for bacteria. Another hypothesis is that the superabsorbent fibers in the tampons can scratch the surface of the vagina, making it possible for bacteria or their toxins to enter the bloodstream.

Symptoms of toxic shock syndrome include:

5. Sudden high fever

6. Low blood pressure

7. Vomiting or diarrhea

8. A rash resembling a sunburn

9. Confusion

10. Muscle aches

11. Redness of the eyes, mouth and throat

12. Seizures

13. Headaches

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To reduce chances of contracting toxic shock syndrome women should change tampons frequently, at least every four to eight hours. Using lower absorbency tampons also reduces risks.

Transgender Adolescents and Puberty Blockers

For some teens and preteens, especially those who are gender expansive or transgender, puberty (and the process of menstruation) is especially difficult. Transgender refers to individuals whose internal sense of gender identity does not correspond with biological gender (as compared with cisgender individuals, whose internal sense of gender identity biological gender are congruent). Gender expansive/gender creative individuals are those who do not identify in terms of traditional gender norms of male/female.

Transgender people may experience gender dysphoria when biological processes, such as menstruation occur. Trans men, who were born into a biologically female body and who go through puberty and menstruate, may reference depression and negative feelings when they menstruate. Similar feelings occur for trans women, who also develop external secondary sex characteristics (facial hair, muscle development) during puberty.

Medical interventions such as hormone therapy or puberty blockers (medications that are prescribed to inhibit puberty by suppressing the production of sex hormones) may be prescribed to children who are gender expansive. This is a way of allowing children and their families time to make gender decisions prior to them going through the physical process of puberty. Suppressing endogenous pubertal changes may lessen individual’s gender dysphoria and ultimately make cross hormone therapy is more effective at achieving the desired physical appearance in gender transition.

Puberty blockers suppress the release of LH and FSH from the pituitary gland. This then stops estrogen from being released from the ovaries in biologically female children and testosterone from being released from the testes in biologically male children. Without exposure to sex hormones the body does not undergo the physical changes associated with them.

Puberty blockers have many uses. In addition to their use with gender expansive children, they may also be prescribed for children experiencing precocious puberty (in this case these agents would be stopped when the child is mature enough to begin puberty). They are also used for treatment of certain sex hormone sensitive cancers, like prostate cancer, to prevent the individuals from being exposed to hormones that can increase cancer growth. They may also be prescribed to adults who are undergoing cross-gender transition. By suppressing the individual’s production of sex hormones, administering cross hormone therapy for transition is more effective.

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Puberty blocking agents include:

• Leuprolide or Depot Lupron: An injectible medication that is given on either a monthly or every 3 month basis.

• Suprellin or Histrelin: This form is an implant. A very small device is implanted under the skin of one’s upper arm, and slowly releases medication over a period of one year.

Menstrual Problems

Some women have their monthly menstrual cycles and find them to be a relatively painless/stress-free experience while others experience a variety of physical or psychological symptoms. Some of the common menstrual problems are described below.

Dysmenorrhea

Dysmenorrhea or painful menstruation is the most common menstrual problem. Its prevalence is estimated at 25% of women and up to 90% of adolescents (Durain, 2004). The most common symptom of dysmenorrhea is cramping pain in the pelvic region but may also include headaches, backaches, nausea, and pelvic bloating and pressure.

Although there are many possible causes of dysmenorrhea, one common hypothesis involves postaglandins, hormone-like substances produced in the lining of the uterus. These chemicals cause the uterine muscles to contract. Women with severe menstrual pain generally have higher levels of postaglandins.

Treatment generally involves the use of over-the-counter medications, such as aspirin, or Midol. Naprosyn, which is a prescription medication, is also widely used for symptoms of dysmenorrhea. Dietary changes such as a decrease in caffeine intake, and aerobic exercise may also be helpful.

Endometriosis

Endometriosis is the abnormal growth of endometrial cells similar to those that form the inside of the uterus, but in a location outside of the uterus (such as in the fallopian tubes,

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42 bladder, vagina or cervix). Symptoms of endometriosis vary depending on the location of the growth. Many women who have endometriosis do not have symptoms. The common symptoms are pelvic pain, which usually occurs during or just menstruation and lessens after menstruation. Some women also experience painful sexual intercourse or cramping during intercourse, or pain during bowel movements or urination. The pain intensity can change from month to month. Many with endometriosis also have fertility issues.

Endometriosis can be treated with medications and/or surgery. Nonsteriodal anti- inflamatory drugs (NSAIDs) can be used to help relieve pelvic pain and menstrual cramping. Oral contraceptive pills are also used to treat endometriosis. Surgery is more of a last resort when symptoms of endometriosis are severe or when there has been an inadequate response to other treatment.

Amenorrhea. Another common menstrual problem is amenorrhea, or the absence of menstruation. Primary amenorrhea is the absence of any menstrual cycle (generally age 18 is used as a guideline). Secondary amenorrhea is the absence of menstruation for 6 or more months in a woman who has already started menstruation and who is not pregnant, breastfeeding or in menopause. Secondary amenorrhea can be related to medical conditions such as hormonal imbalances, disease, stress, nutritional deficits (such as an eating disorder), excessive body weight, or more than 8 hours of vigorous exercise a week.

Psychological Problems Associated with Menstruation

In addition to the biological aspects of menstruation, mental health professionals also need to be aware of psychological problems. Psychological and cultural attitudes towards menstruation have alternated between repulsion and celebration. Some cultures revere menstruation as intimately connected with the renewal of life. Others fear menstruation and separate menstruating women as a way not to contaminate men. It is interesting to study how cultures view menstruation, and certain themes emerge that seem to be applicable across cultures. This has been a focus on study in diverse cultures. Adegbayi (2017) for example looked at the impact of menstruation on women in Nigeria, exploring menarche narratives of 136 women, as well as sources of premenstrual information and how the menstrual period was managed. Adegbayi found that almost all of the respondents (95%) had received information about menstruation from mothers, female relatives and school prior to menarche. Many of the respondents viewed their first period as a “crisis.” Two primary themes emerged from the contents of the narratives; celebration and advice. The advice theme was further explored and patterns were identified: respondents discussed seeking advice about being a woman, hygiene and changed dynamics in relationships with males.

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The biological process of menstruation is neither physically nor psychologically debilitating. That does not mean, however, that it is a time in which there are not challenges. The term “premenstrual tension” was coined in 1931 and used to refer to the mood changes that happen during the of the menstrual cycle. Symptoms of premenstrual tension are numerous, and include depression, irritability, fatigue and headaches. Many women experience these symptoms to a greater or lesser extent. The term premenstrual syndrome (PMS) is reserved for symptoms that are incapacitating enough to interfere with performance of daily activities. More common symptoms include mood swings, irritability, abdominal bloating, breast tenderness, changes in appetite, headache, anxiety and crying spells. Many causes of PMS have been suggested, including progesterone deficiency, fluid balance abnormalities, and nutritional deficiencies. However, there is no scientific evidence to unequivocally support any of these as the sole cause of PMDD. Risk factors for PMDD also include environmental factors, including stress, history of interpersonal trauma, seasonal changes, sociocultural aspects of female sexual behavior and female gender role conflicts (DSM-5). There does seem to be a genetic basis to PMDD, with estimates for heritability ranging from 30-80% (DSM-5). Treatment of PMS may include dietary changes, exercise or prescribed medications (oral contraceptives, antidepressant, NSAIDs) Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome, affecting 1.8-5.8% of menstruating women (DMM-5). Women with a personal or family history of depression or postpartum depression are at greater risk for developing PMDD. Although the exact cause of PMDD is not known, most researchers believe that PMDD is brought about by hormonal changes related to the menstrual cycle. Studies have shown a connection between PMDD and low levels of serotonin. The onset of PMDD can occur at any point after menarche. Many people report that symptoms increase with age and end at menopause. For postmenopausal women, hormone replacement can trigger re-expression of symptoms. The PMDD criteria of the DSM-5 require the presence of 5 symptoms to make the diagnosis of PMDD. In the majority of menstrual cycles the symptoms must be present in the final week before onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. Thus, symptoms must be discretely related to the menstrual cycle and must not merely be a worsening of preexisting depression, anxiety, or personality disorder. These symptoms must be associated with clinically significant stress or interference with work, school or relationships with others (such as avoidance of social activities.) Symptoms should also not be better explained by another medical or psychological condition. DSM criteria for Premenstrual Dysphoric Disorder

1. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection) 2. Marked irritability or anger or increases interpersonal conflicts 3. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

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4. Marked anxiety, tension, feelings of being "keyed up" or "on edge" 5. Decreased interest in usual activities (e.g., work, school, friends, hobbies) 6. Subjective sense of difficulty in concentrating 7. Lethargy, easy fatigability, or marked lack of energy 8. Marked change in appetite, overeating, or specific food cravings 9. Hypersomnia or insomnia 10. A subjective sense of being overwhelmed or out of control 11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain

DSM-5 diagnosis requires that symptoms be confirmed through daily ratings during at least two menstrual cycles. Some possible scales to measure this are the Daily Rating of severity Problems and the Visual Analogue Scales for Premenstrual Mood Symptoms. When less that 5 symptoms are present, the diagnosis of Premenstrual Syndrome is appropriate. This is basically a less severe form of PMDD. Many of the same strategies used to treat PMS are also helpful in relieving symptoms of PMDD. The four main forms of treatment are: Nutrition. Limit intake of salt, caffeine, refined sugar, and alcohol. Natural supplements, such as calcium, vitamin B6, vitamin E, chasteberry, and magnesium may be helpful although, their effectiveness has not been well-studied.

Exercise. Regular aerobic exercise such as walking or swimming appears to improve premenstrual symptoms.

Antidepressant Medications. Several antidepressants may be used to treat PMDD. The drugs approved by the FDA for the treatment of PMDD are Sarafem (Fluoxetine), Paxil CR, and Zoloft. These medicines can be taken continuously or intermittently, just during the 14-day premenstrual period. Taking them intermittently may decrease the side effects of these drugs. Further study is needed (Pearlstein, 2012).

Hormones can be used to treat PMDD. Ovulation can be stopped either using medication or surgically (as a last resort). Medicines used to stop ovulation include birth control pills, Danazol, Zoladex, Synarel, and Lupron. The second hormonal approach to treat PMDD is the use of progesterone or estrogen to relieve symptoms. It's unclear whether this approach is effective.

Counseling/Cognitive-Behavioral Therapy. Therapy to help women with PMDD develop effective coping strategies may help some with PMDD. CBT strategies for PMDD include

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45 identifying emotions, use of thought records, generating coping thoughts, problem-solving and relaxation strategies. Meditation, reflexology, and yoga may also help.

Puberty in Boys

As with females, boys experience a variety of physical and emotional changes during the period of growth known as puberty. Puberty is the period of sexual maturation and achievement of fertility. Boys enter puberty at a later age than girls, generally between the ages of 9.8 and 14.2 years (Westwood & Pinzon, 2008). Within those ages, there is variability, and for some boys full maturation may not occur until age 16 or so. As with girls, puberty is a process signaled by hormonal changes (especially testosterone) and characterized by a series of predictable physical changes.

Enlargement of the and

In boys, the first change observed at the onset of puberty is an increase in the size of the testicles. The process of enlargement begins at about 11 and a half years and lasts for six months. This increase in size is significant, and most boys’ testicles nearly double in size. Growth is also observed in the scrotal sac.

Growth of Pubic/Body Hair

After the initial testicle growth, puberty progresses at a rapid pace. Testosterone surges, causing growth of pubic hair. At first this growth is light/downy, but soon becomes darker/coarser. About two years after the appearance of pubic hair, sparse hair begins to sprout on a boy's face, legs, arms and underarms, and chest.

Changes in Body Shape/Weight

Just prior to the onset of puberty, most boys appear stocky but gangly – extremities longer than the trunk. As they progress into puberty, there is a growth spurt, which peaks during During this growth spurt, body proportions change. There is rapid growth of the trunk and legs.

Boys continue to develop muscle mass. By late teens, a boy's body composition is about 12 percent fat. While boys have an increase in the growth of body fat, their muscle growth is

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46 faster. By the end of puberty, boys have a muscle mass about one and a half times greater than that of comparably sized girls.

Penis Growth

There is great variety in attainment of penis growth during puberty. A boy may have adult- size genitals as early as age thirteen or as late as eighteen. Another alteration in penis appearance involves papules — pink, pimple-like marks around the crown of the penis. About one in three adolescent boys have these papules.

Fertility

Near the onset of puberty, a surge in testosterone triggers the production of . Boys are then fertile and can father children. Another common aspect of this testosterone increase at puberty involves erections, which can occur involuntary. (“wet dreams”) can – and frequently do – occur during sleep.

Voice Change

Following the peak of the growth spurt, a boy's larynx and vocal cords enlarge. The voice may "crack" as it deepens. For a while, a boy might find his voice goes very deep one minute and very high the next. Once the larynx reaches adult size, this stops.

Tanner Stages

As with girls, physical changes in boys are predictable. The chart below describes these stages.

Tanner Stages (James M. Tanner) – Boys Sexual Maturity Rating

Development Of External Genitalia

Stage 1: Prepubertal

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Stage 2: Enlargement of scrotum and testes; scrotum skin reddens and changes in texture Stage 3: Enlargement of penis (length at first); further growth of testes Stage 4: Increased size of penis with growth in breadth and development of glans; testes and scrotum larger, scrotum skin darker Stage 5: Adult genitalia

Pubic Hair

Stage 1: Prepubertal Stage 2: Sparse growth of long, slightly pigmented hair, straight or curled, at base of penis Stage 3: Darker, coarser and more curled hair, spreading sparsely over junction of pubes Stage 4: Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs Stage 5: Adult in type and quantity

Growth

Stage 1: 5-6cm/year Stage 2: 5-6cm/year Stage 3: 7-8cm/year Stage 4: 10 cm/year Stage 5: No further height increase after 17 years

Psychological Adjustment in Pubescent Boys

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Young men may experience a variety of concerns during puberty, although they are less likely than girls to be seen in a clinical setting, although there has been an increased trend in the psychological literature to look at the specific needs of boys and men.

As with girls, boys may have questions about the physical process of maturation, and about the norms of puberty. There is some variety in how quickly boys mature as described earlier. Height, physical appearance, and genital development are often things that pubescent boys think about, and these types of questions may arise in therapy. Physical anomalies, such as papules may also be concerning, despite their benign nature.

Delayed Puberty

Delayed puberty is defined as no evidence of an increase in testicular volume (greater than or equal to 4 ml) or length (greater than or equal to 2.5 cm) by 15 years of age. Most boys who experience delayed puberty do not have an apparent physical cause, although there is some research into connections to body fat/composition and puberty. Pubertal delay may result in emotional distress, poor body image and low self-esteem and may increase the likelihood of boys being teased or bullied (Girli et al., 2017; Zhu & Chan, 2017). Due to these concerns, researchers have looked at the effects of testosterone therapy, such as to increase height and allow boys to reach heights more congruent with peers at an earlier age (Girli et al., 2017).

Precocious Puberty

Precocious puberty in males is defined as testicular enlargement before 8.5 years of age or the appearance of pubic hair before age 9. Due to the strong association between precocious puberty and physical concerns (such as intracranial issues) it is important to try to determine if there is something medical that is causing the early puberty. As with delayed puberty, maturing early has psychological ramifications (Sun et al., 2016). Boys who mature earlier may be expected to conform to more adult norms or they may be sexually active at an earlier age (Westwood & Pinzon, 2008). They may also engage in risk taking behaviors (Sun et al., 2016).

Gynecomastia

Gynecomastia is a condition in which there is an increase in male breast tissue. Up to 70% of adolescent boys experience some breast development, often during the middle stages of puberty (Niewoehner & Schorer, 2008). When present, gynecomastia is generally mild – less than 3 cm to 4 cm, although obesity may worsen this condition. While there may be an underlying medical condition, during puberty, gynecomastia is most often related to changes in hormone levels. Despite the frequency of gynecomastia, many boys who may find breast development embarrassing or worry that there is something abnormal about them. Reassurance about the prevalence and causes of this condition are often helpful in allaying anxiety.

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Summary

Adolescence is a time of significant physical and psychological change. These changes are consistent and predictable. While there is no “typical” response in terms of adjustment to physical changes, although most adolescents do not experience any psychological distress. Deviations from the norm, actual or perceived, are sometimes related to such distress. Clinicians who assume a supportive/psychoeducational response to concerns often experience the greatest efficacy.

Chapter 4 Topics in Human Sexuality: Fertility

Introduction

Case Vignette 1 Joanne, who is 24 and her husband John, age 28 have been trying to conceive a child for the past year. Joanne is particularly upset about the fact that she is not pregnant as she has always seen herself as a mother. John is more ambivalent, stating that they are happy as a couple, and a child isn’t essential. Joanne has become increasingly more depressed, and is crying when she sees another couple with a baby. This has created a great deal of friction with John, who thinks she needs to “relax more” and states he would be happy even if it remains the two of them. Joanne is angry, and questions whether John will support her in her quest to have a baby.

Case Vignette 2 Jamie is a 35-year-old single lesbian woman. She is successful and well established career- wise, and feels that having a child would fulfill her even more. She has been able to work with a man who is providing donor sperm, and has been attempting self-inseminations. It has now been a year, and she has not been able to become pregnant. This had led to a myriad of emotions (anger, sadness) and while she would like to seek support from a specialist there are also fears that they will not be supportive of her status as a potential single mother.

The case vignettes above illustrate many of the factors seen in individuals and couples experiencing fertility issues. Many men and women assume that the ability to become pregnant when they are ready is a given. In fact, pregnancy is a complex process, and can become derailed at any point. Infertility is actually a common problem. According to the Centers for Disease Control and Prevention (CDC, 2002), approximately ten percent of women, or 6.1 million women in the United States have difficulty getting pregnant or staying pregnant. The World Health Organization estimates that 10-15% of couples worldwide experience infertility (Deka & Sarma, 2010). Of these couples, many seek fertility treatment.

Infertility may be the result of many causes. Fertility concerns may be related to the male or female partner. There are currently many effective therapies for overcoming infertility.

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The process of fertility treatment is stressful, physically as well as emotionally. Many women and couples experiencing infertility keep the struggle private, and do not have sources of support. Couples need to learn a new language rife with medical terminology. Treatment demands may add stress to the relationship. Even with treatment, there are not guarantees that the couple will be successful in achieving a pregnancy. For this reason, counselors need to be aware of the issues surrounding infertility and fertility treatment.

This chapter will provide an overview of fertility. After completing this module, clinicians will be more aware of the factors associated with fertility treatment.

Objectives

1. Define infertility, and list the stages of conception. 2. List common fertility problems in women. 3. Describe fertility testing in women. 4. Discuss factors contributing to male factor infertility. 5. Describe components of a sperm analysis. 6. Discuss infertility treatment options. 7. Describe the use of Intrauterine (IUI). 8. Discuss the various types of Assisted Reproductive Technologies (ART). 9. Define and discuss selective reduction. 10. Discuss the use of surrogacy/gestational carriers. 11. Describe emotional aspects of infertility, and effective treatments for infertility stress (CBT, ACT).

Defining Infertility

Infertility is defined as the inability to become pregnant after one year of not being able to get pregnant despite having frequent, unprotected sex for at least a year. If a woman is 35 years of age or older she would be considered to be infertile after six months. Women who can become pregnant but are unable to stay pregnant due to miscarriage may also be considered to be infertile.

For couples in which there are no fertility issues, most achieve pregnancy within the first six months of actively trying to conceive. After 12 months of unprotected intercourse about 90 percent of couples will become pregnant.

Conception

In order to better understand infertility and the treatment processes that accompany fertility treatment, it is important to review what occurs during conception.

Conception involves six primary processes. These are:

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• Production of follicle stimulating hormone (FSH) • The release an egg or from the ovaries (ovulation). • Development of the follicle into the corpus luteum (luteal phase) • The egg is released through a fallopian tube and travels toward the uterus (release) • The man's sperm penetrates the egg resulting in the zygote (fertilization). • The fertilized egg attaches to the inside of the uterus (implantation).

Infertility can occur if there are problems with any of these steps. That said, infertility is not always due to physiological problems with the woman (female factor infertility). In fact, about one third of fertility issues are due to the woman; another one third of fertility problems are due to the man. Another one third of cases are caused by a mixture of male and female problems or cannot be traced to a cause (unexplained infertility).

Conception

Role of FSH The body begins to produce follicle-stimulating hormone (FSH) several days after the onset of menses. The increased levels of FSH result in the formation of a mature egg-containing follicle on one of the ovaries.

Ovulation A woman’s ovaries contain about 400,000 small fluid-filled cysts, known as ovarian follicles by the time she reaches puberty. Each ovarian follicle contains a hollow ball of cells with an immature egg in the center. Each month, between ten and 20 follicles begin the process of maturation. Generally only one of the follicles actually develops completely (maturation). The dominant follicle contains the growth of any other less mature follicles. These stop growing and break down.

The Corpus Luteum (Luteal Phase) Following ovulation, the ruptured follicle develops into a structure called the corpus luteum. The corpus luteum secretes progesterone and estrogen. These hormones, particularly the progesterone, cause changes in the lining of the uterus. The lining thickens, which makes it more suitable for implantation of the fertilized egg and the nourishment of the embryo.

Release of Egg When the follicle has adequately matured, a surge of luteinizing hormone (LH) is triggered. This surge will prompt the follicle to burst and release the egg into the fallopian tube, where fertilization may take place. Fertilization can take place for about a 24-hour period after ovulation. On average, ovulation and fertilization occurs about two weeks after the woman’s last menstrual period. If the egg is not fertilized, the corpus luteum becomes inactive after 10–14 days and menstruation occurs. This causes the endometrium, the inner membrane of the uterus, to slough off, resulting in menstrual bleeding.

Fertilization

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If sperm does meet and enter a mature egg after ovulation, it will fertilize it. When the sperm enters the egg, changes occur in the protein coating around it. These changes prevent other sperm from entering the egg. At the time of fertilization, the resulting baby's genetic make-up is complete and contains all genetic information, including the child’s gender.

Implantation Within 24-hours after fertilization, the egg begins dividing rapidly into many cells. The egg remains in the fallopian tube for approximately three days. The fertilized egg, now called a zygote, continues to divide as it passes through the fallopian tube. It then enters the uterus attaches to the endometrium. The zygote first becomes a solid ball of cells, then changes into a hollow ball of cells called a blastocyst. Before implantation, the blastocyst ruptures its protective covering. The blastocyst then establishes contact with the endometrium, an exchange of hormones helps the blastocyst attach. The endometrium then becomes thicker and the cervix (neck of the uterus ) is sealed by a plug of mucus. Within three weeks, the blastocyst begin to grow and the baby's first nerve cells form. The developing baby is called an embryo from the moment of conception to the eighth week of pregnancy.

Fertility Problems in Women

Although it is impossible to provide an exhaustive list of what causes fertility problems in women, there are a number of more commonly seen concerns. These are:

Ovulation Disorders. Without ovulation, there are no eggs to be fertilized. Signs that a woman is not ovulating normally include irregular or absent menstrual periods. Ovulation problems are often caused by polycystic ovarian syndrome (PCOS) a hormonal imbalance that can interfere with normal ovulation. Primary ovarian insufficiency occurs when a woman's ovaries stop working normally before she is 40. This differs from early menopause, as women with primary ovarian insufficiency are able to become pregnant with treatment; women who have gone through menopause cannot. The exact cause of primary ovarian insufficiency is unknown, but it does appear to run in families. Ovulation disorders are discussed in more detail below.

Blocked fallopian tubes. If fallopian tubes are blocked, it will prevent the egg from being available to be fertilized. Blocked fallopian tubes may be the result of pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy.

Physical problems with the uterus. A healthy uterus or womb is where the embryo will reside. Physical problems of the uterus may include uterine fibroids, non-cancerous clumps of tissue and muscle on the walls of the uterus. Uterine fibroids do not always result in infertility.

Other things that can contribute to female factor infertility include:

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• Age. As women age, their ovaries become less able to release eggs, there are a smaller number of eggs left, and egg quality is diminished.

• Excess alcohol use. Alcohol abuse is associated with hypothalamic-pituitary-ovarian dysfunction resulting in amenorrhea (absence of menses), anovulation (lack of ovulation), and luteal phase defect (abnormal development of the endometrial lining).

• Excessive stress. Chronic stress affects the hypothalamus, the part of the brain that controls the release of hormones.

• Poor diet. If diet is poor, the body does not have the proper nutrients necessary to maintain reproductive health.

• Weight. Excessively high or low weight can affect fertility. Weight loss of 5% to 10% may dramatically improve ovulation and pregnancy rates. Overweight women are at increased risk for infertility and miscarriage. Both under and overweight women may have irregular menstrual cycles (American Society For ).

• Some health problems also increase the risk of infertility:

- Irregular periods or no menstrual periods - Endometriosis - Pelvic inflammatory disease

Ovulation Disorders

Ovulatory disorders are one of the leading causes of infertility. In anovulation eggs do not develop properly, or are not released from the follicles of the ovaries. Women with anovulation may not menstruate for several months. Others may menstruate, although they are not ovulating. Anovulation may result from hormonal imbalances, eating disorders, and other medical disorders. Often, however, the cause is often unknown.

Oligo-ovulation is a disorder in which ovulation doesn't occur on a regular basis. In oligo- ovulation the menstrual cycle may be longer than the normal cycle of 21 to 35 days.

The treatment for ovulation disorders generally involves medication to stimulate ovulation. A commonly prescribed medication is Clomid. Ovulation is generally carefully monitored through ultrasound and blood tests.

Luteal Phase Defect

Luteal phase defect is a common but misunderstood condition that frequently affects fertility. The luteal phase of the menstrual cycle spans the time between ovulation and the

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54 onset of the next menses. Luteal phase defect is a failure of the uterine lining to be in the right phase at the right time. Since embryo implantation is highly dependent on the state of the lining, Luteal phase defect can consistently interfere with a woman's ability to get pregnant and carry a pregnancy successfully.

A normal cycle can be disrupted in several places: poor follicle production, premature demise of the corpus luteum, and failure of the uterine lining to respond to normal levels of progesterone. These problems can also be found in conjunction with each other.

Diagnosis of Female Infertility

Diagnosis of female factor infertility generally involves a thorough medical history and tests:

• FSH blood level - measures the amount of follicle stimulating hormone (FSH) in the blood. FSH stimulates production of eggs and a hormone called estradiol during the first half of the menstrual cycle.

• Progesterone blood level - Serum progesterone is a test to measure the amount of progesterone in the blood. Progesterone is a hormone produced in the ovaries. Progesterone helps ready the uterus implantation of a fertilized egg.

• Ultrasound - Used to determine if follicles developing; time follicles are released and to evaluate ovarian function.

• Endometrial biopsy - a procedure in which a sample of endometrial tissue is examined to determine if it is developed enough to support a pregnancy. This is often used in diagnosing luteal phase defects.

• Hysterosalpingography. An x-ray of the uterus and fallopian tubes. Doctors inject a special dye into the uterus through the vagina. The physician can then watch to see if the dye moves freely through the uterus and fallopian tubes in order to look for physical blocks that may be causing infertility.

• Laparoscopy. A minor surgery to look inside the abdomen. With the laparoscope, the doctor can check the ovaries, fallopian tubes, and uterus for disease and physical problems.

Male Infertility

Infertility in men is most often caused by problems that affect the sperm. Sperm production is actually a complex process that involves the testicles and hypothalamus and pituitary glands. Sperm is first produced in the testicles, until they combine with semen and are

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55 ejaculated from the penis. Problems with any of these systems can affect sperm production. In addition, abnormal sperm shape (morphology) and movement (motility) may also negatively impact fertility.

Some commonly seen problems are:

Varicocele. In this condition the veins on a man's testicle(s) are too large. This heats the testicles, which in turn can lead to reduced sperm count and fewer moving sperm.

Sperm duct defects. The tubes that carry sperm can be damaged by illness or injury. Some men are born with a blockage in the part of the testicle that stores sperm or a blockage of one of the tubes that carry sperm out of the testicles. Men with cystic fibrosis and some other inherited conditions may be born without sperm ducts.

Infection. Some infections can interfere with sperm production and sperm health or can cause scarring that blocks the passage of sperm. These include some sexually transmitted diseases, such as Chlamydia and gonorrhea; inflammation of the prostate; and inflamed testicles due to mumps.

Lack of . Some men with spinal cord injuries or certain diseases can't ejaculate semen, even though they still produce sperm.

Hormone imbalances. Low testosterone (male ) and other hormonal problems can lead to infertility.

Seminal fluid abnormalities. If the seminal fluid is very thick, it may be difficult for the sperm to move through it and into the woman's reproductive tract.

Drugs. There are a number of common drugs that may have a negative effect on sperm production and/or function. They include: • Antibiotics: Nitrofuran, Erythromycin, Gentamicin • Methotrexate (cancer, psoriasis, arthritis) • Cimetidine (for ulcer or reflux) • Calcium Channel Blockers (anti-hypertensives)

Other things that can contribute to male factor infertility include:

• Excessive alcohol use. Moderate alcohol use does not affect male fertility. Excessive alcohol is toxic to the gonads. It may also cause liver dysfunction and nutritional deficiencies, which harm sperm production.

• Drugs (marijuana, cocaine, anabolic steroids). These can lead to decreased sperm count, motility, and problems with morphology (sperm shape).

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• Cigarettes. Regular smoking causes a 23% decrease in sperm density and a 13% decrease in motility (The American Society for Reproductive Medicine, 2003).

• Exercise. Long-distance runners and cyclers have decreased , causing sperm cells to divide abnormally.

• Age. Appears to reduce sperm quality (Lawrence Livermore National Laboratory, 2006).

• Radiation treatment and chemotherapy for cancer.

Diagnosis of Male Infertility

The primary test of male infertility is a semen analysis. The semen analysis is used the quality of the man's semen. Since a semen analysis is non-invasive, this is generally one of the first tests performed and may help to reduce the need for more complicated interventions for the female partner. It is also important to rule out significant medical problems that may contribute to a poor semen analysis.

The semen analysis looks at the following:

Sperm Count: Measures of how many million sperm there are in each milliliter of fluid. Average sperm concentration is more than 60 million per milliliter. Low sperm counts can play a significant role in fertility. . This condition is known as oligospermia, and is seen in up to 20% of male infertility. There may or may not be a known cause for this condition. Very low sperm count is one of the considerations in the option to use donor sperm.

• Mild: concentrations 10 million – 20 million sperm/mL • Moderate: concentrations 5 million – 10 million sperm/mL • Severe: concentrations less than 5 million sperm/mL • If there are no sperm at all in the semen sample, the condition is termed azoospermia

Motility. Determines the percentage of sperm that are moving. The norm is fifty percent or more. This is also a consideration in the option to use donor sperm.

Total motile count. This is the number of moving sperm in the ejaculate. There should be more than 40 million motile sperm.

Morphology: This determines the shape of the sperm. Most laboratories use (use World Health Organization (WHO) criterion. Thirty percent of the sperm should be normal by these criteria.

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Volume. This is a measurement of the volume of the ejaculate. Normal is two milliliters or greater.

Standard semen fluid tests: Looks at color, viscosity (thickness), and the time until the specimen liquefies.

Causes of Male Infertility/Problems with Sperm

Damage to the testes (e.g., from mumps, radiation or chemotherapy, trauma, or surgery)

Hormonal imbalances (Anything that lowers LH and FSH levels, such as a pituitary tumor, can result in low or no sperm production and low testosterone levels).

Heat can have a detrimental effect on normal sperm production. Soaking in a bathtub full of hot water can almost halt sperm production completely. • Obesity can cause fertility concerns because the sagging layers of fat can overheat the testicles • Men whose jobs involve long hours of sitting, e.g. truck drivers may have infertility due to the increased heat to the genital area

Very frequent intercourse/ejaculation can lead to the demand exceeding the supply. There are quite a number of infertile men whose sex drive is such that they must ejaculate 2-3 times a day thus giving them a lower sperm count.

Stress and fatigue can potentially interfere with sperm production.

Chemical factors • Smoking over 20 cigarettes a day has been shown to reduce both the sperm count and sperm motility • Excessive alcohol intake can lower the production of sperm and of the male hormone testosterone. • Use/abuse of anabolic steroids • Chemotherapy • Use of antibiotics (including erythromycin, tetracycline, gentamycin); conversely antibiotics may be prescribed on a temporary basis to clear infections • Blood pressure medications

Many sperm problems can be treated, depending on the cause of the problem. The use of medication (LH and FSH hormone injections) or surgery (such as for men with blockages) can be helpful. Some situations will require use of advanced reproductive technologies (ART), or in some cases donor sperm.

Fertility Treatment

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Infertility can be treated with medication, surgery, intrauterine insemination, or assisted reproductive technology. Often these treatments are combined.

Common Fertility Medications

Fertility medications are used to stimulate ovulation in women with ovulatory disorders or to support the use of intrauterine insemination or assisted reproductive technologies by controlling the process of ovulation.

• Clomiphene citrate (Clomid/Serophene): Acts on the pituitary gland to stimulate ovulation. Often used in women who have PCOS, and because it is given orally is a firstline medication for infertility. Clomid can cause changes in the cervical mucus, which may inhibit the sperm from entering the uterus. This drug is often used along with other fertility methods, like assisted reproductive techniques or artificial insemination.

• Human menopausal gonadotropin or hMG (Novarel, Ovidrel, Pregnyl, and Profasi): hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.

• Follicle-stimulating hormone or FSH (Bravelle, Fertinex, Follistim, Gonal-F): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are injected.

• Gonadotropin-releasing (Gn-RH) agonists (Lupron, Synarel, and Zoladex.) Gn- RH agonists act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.

These medications can cause hot flashes, blurred vision, nausea, bloating, and headache, and moodiness. They also increase the changes of twins, triplets or multiple births.

Other Medications

• Metformin (Glucophage): Used for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions, which helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken orally.

• Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of .

• Antagon ( ganirelix acetate). It's an injected drug that can prevent early ovulation in women who are having fertility procedures.

• Heparin. Is used to lower the risk of miscarriage in some cases.

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Intrauterine insemination (IUI)

Intrauterine insemination (IUI) is fertility treatment that uses a catheter to place a washed sperm directly into the uterus. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and increase the chance of fertilization. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.

IUI is often used to treat: • Mild male factor infertility (low sperm count, decreased mobility) • Women who have problems with their cervical mucus • A unreceptive cervical condition, such as cervical mucus that is too thick • Ejaculation dysfunction • Couples with unexplained infertility • Use of donor sperm

IUI is not recommended for the following patients: • Women who have severe disease of the fallopian tubes • Women with a history of pelvic infections • Women with moderate to severe endometriosis

Younger women usually have higher rates of success compared to women over age 35. The average success rate for IUI ranges from 10-20% in one cycle. With IUI, the success is dependent on the health of the sperm and the woman's body.

Assisted Reproductive Technology (ART)

Assisted reproductive technology (ART) methods work by removing eggs from a woman's body. The eggs are then mixed with sperm to produce embryos. The embryos are then put back in the woman's body. ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos.

Success rates vary and depend on many factors including (CDC, 2016): • Age of the partners • Reason for infertility • Type of ART • Fresh or frozen ART cycle

The most recent data on ART is from 2014. The data for this national report come from the 458 fertility clinics in operation in 2014 tha provided and verified data on the outcomes of all ART cycles started in their clinics. Of the 208,604 ART cycles performed in 2014 at these reporting clinics, 173,198 cycles (83%) were started with the intent to transfer at least one embryo. These 173,198 cycles resulted in 57,323 live births (CDC, 2014).

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Methods of ART include:

• In vitro fertilization (IVF) means fertilization outside of the body. IVF is considered to be the most effective type of ART. IVF is often used when a woman's fallopian tubes are blocked or when a man produces too few sperm. In a typical IVF cycle, the woman is given medication acts directly on the ovaries to stimulate ovulation with the goal of producing multiple eggs. Injected medications such as Repronex or Pergonal are common choices. Once mature, the eggs are removed. In a laboratory setting, the eggs are combined with sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman's uterus.

• Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus. ZIFT is used when there is a tubal blockage/significant tubal damage or there is an anatomic problem with the uterus, such as severe intrauterine adhesions.

• intrafallopian transfer (GIFT) involves transferring eggs and sperm into the woman's fallopian tube. One of the main differences between this procedure and in vitro fertilization (IVF) and zygote intrafallopian transfer (ZIFT) procedures is that the fertilization process takes place inside the fallopian tubes rather than inside the laboratory.

• Intracytoplasmic sperm injection (ICSI) is often used for couples in which there are significant problems with the sperm and sometimes in the case of a vasectomy reversal. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.

Selective Reduction

With fertility medications there is a greater likelihood of conceiving twins or triplets. Additionally many ART procedures implant more than one embryo in order to increase the likelihood of a successful pregnancy. Selective reduction (or fetal reduction) is a procedure in which one or more fetuses is aborted in a in a multifetal pregnancy. The purpose of selective reduction is to lessen the medical issues related to multiple births. The goal of selective reduction is to increase the chance of a successful, healthy pregnancy. Multifetal pregnancy reduction: is usually done early in a pregnancy, between the 9th and 12th weeks, is most often done when there are four or more fetuses present.

The most common risk involved with multiple births is preterm labor. Nearly half of all twins are born prematurely, and the risk of having a premature delivery (prior to 37 weeks) increases with triplets, quadruplets, etc. Babies born prematurely may have numerous health challenges.

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Premature babies can have numerous health challenges. Prematurity accounts for 10% of neonatal mortality worldwide. Premature births have also been associated with (American Pregnancy Association, n.d.):

• Neurological problems including developmental disability, cerebral palsy and intraventricular hemorrhage • Cardiovascular complications • Respiratory problems are common, specifically respiratory distress syndrome and chronic lung disease • Gastrointestinal and metabolic issues such as feeding difficulties and hypoglycemia • Infections, including sepsis, pneumonia, and urinary tract infection

The most common method of fetal reduction is transabdominal (through the belly). For this procedure, the doctor uses ultrasound as a guide and inserts a needle through the woman's abdomen and into the uterus to the selected fetus. The doctor injects the fetus with a potassium chloride solution, which stops the fetal heart. Because it is very small during the first trimester, the fetus is usually absorbed by the mother's body.

Despite some of the difficulties associated with preterm labor and delivery, selective reduction is a decision that is very emotional for a couple to make, particularly following experiences with infertility. Couples considering selective reduction should be provided with counseling to support them in this decision.

Surrogacy/Gestational Carrier

Women with no eggs or unhealthy eggs may choose surrogacy as an option. A surrogate is a woman who agrees to become pregnant using the man's sperm and her own egg. The child is genetically related to the surrogate and the male partner. After birth, the surrogate agrees give up the baby for adoption by the parents.

Women with ovaries but no uterus may choose a gestational carrier. This is also an option for women who shouldn't become pregnant because of a serious health problem. In this case, IVF is performed and the resulting embryo is transferred to the gestational carrier. The carrier will not be genetically related to the baby and gives him or her to the parents for adoption at birth.

Söderström-Anttila, Wennerholm, & Loft, A. et al. (2016) looked at 55 cases in which families conceived children using surrogacy. They found that the he medical outcome for the children was satisfactory and comparable to previous results for children conceived after fresh IVF and donation. At the age of 10 years there were no major psychological differences between children born after surrogacy and children born after other types of assisted reproductive technology (ART) or after natural conception.

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Emotional Aspects of Infertility

Case Vignette Marla is a 26-year-old married woman. She and her husband Steve have been experiencing fertility concerns for the past year and a half. The fertility is unexplained, and the specialist has done two IVF cycles so far. Both have been unsuccessful. Marla has become increasingly depressed with each failure. Steve is worried about Marla’s wellbeing, and stressed about the couple’s financial outlay. The precipitant to seeking family support was a recent conflict in which Steve suggested that they take a break from fertility treatment, and Marla became angry and overwhelmed, stating that she feels “worthless” and if she can not be a mother she does not see the purpose in living.

As suggested by this case vignette, going through the fertility process is very difficult from an emotional standpoint. Parenthood is one of life’s major adult transitions. According to the U.S. Census Bureau (2006) 28% of women between the ages of 30 to 34 were childless, and 20% of women between 35 to 39 were childless. Although in general childless young adults report better wellbeing than parents, women experiencing fertility concerns report significant emotional distress (McQuillan et al., 2013). Thus there is a difference between voluntary and involuntary childlessness.

The stress of infertility has been associated with emotional concerns such as anger, depression, anxiety, marital problems and feelings of worthlessness among the parents (Crawford, Hoff & Mersereau, 2017; Deka & Sarma, 2010.) Because infertility may be something that is not openly discussed, people going through fertility issues may feel isolated. The emotional aspects of infertility affect both members of couples, but women may demonstrate more overt distress than men (De Beradis et al., 2014). This may be in part due to social pressures and expectations that women become mothers, and may be more pronounced in women who have generally been successful in other life endeavors, leading them feel valueless.

McQuillan et al., (2013) states that for many women and couples the inability to conceive is an unwelcome surprise. They point to identity theory, and societal expectations of couples that they become parents. This inability to achieve a successful pregnancy may lead to a disruption in identity. McQuillan et al.,’s study of distress among a large sample of Midwestern women experiencing fertility issues indicated that these women experienced significant stress associated with their inability to become mothers. Women in this sample who eventually became mothers, rather through adoption or success with fertility efforts did not experience long-term distress. This study focused on role attainment, and did not include partners. It also did not look at concrete aspects of the fertility process, such as medical interventions associated with fertility attainment.

There are also stresses associated with fertility treatment itself, and how it affects the couple’s sexual life and practices as well as their overall relationship. The need to be intimate at proscribed times may limit spontaneity. These pressures have also been associated with performance concerns in male partners. Individuals and couples can also

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63 struggle with decisions about what steps they should ultimately pursue in their efforts to conceive. Many options, such as in vitro fertilization (IVF), are frequently uninsured, and unaffordable for many. Other alternatives, such adoption or surrogacy can be just as, or more, expensive and pose their own emotional and other challenges.

Given these challenges, it is helpful to look at the effectiveness of psychotherapy for easing stress connected to fertility concerns or for increasing possible fertility outcomes. Two common forms of fertility counseling are cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). Studies suggest that both types of fertility counseling (either individual or group support) may be beneficial.

A meta analysis by Frederiksen et al. (2015) evaluated the effectiveness of psychosocial interventions for improving pregnancy rates and reducing distress for couples in treatment with assisted reproductive technology (ART). While nor every couple will choose this route for fertility, their analysis contains a helpful view of types of interventions commonly seen in therapy. Overall the authors found “robust support” for the role that psychotherapy can play in both reducing psychological distress and in increasing the odds of achieving pregnancy. With regard to psychological wellbeing, the meta analysis demonstrated a reduction in depressive symptoms (significant effect for women only) and a reduction of state anxiety (both men and women). Only five studies included measures of marital function, but only very small non-significant effects were found.

Faramarzi et al. (2008) compared CBT and medication (fluoxetine) in terms of improvement of infertility stress. The researchers studied 89 women. CBT improved the social concerns, sexual concerns, marital concerns, rejection of child-free lifestyle, and need for parenthood more than floxitine group. The researchers concluded that CBT was a reliable alternative to pharmacotherapy, but also superior to fluoxetine in resolving and reducing of infertility stress

CBT treatment for infertility is often time limited (10-12 sessions) and focuses on skills to allow people experiencing these concerns to better cope with the stress. Some of the goals are:

• To establish self-supportive thinking styles with CBT techniques • To understand the relationship between stress and infertility • To integrate mindfulness based relaxation techniques • To decrease any symptoms of stress, anxiety, low-mood and fatigue • Healthy self-care (sometimes including exercise, nutritional support, adjuncts such as yoga or acupuncture) • To self-confidence and empowerment • To learn effective coping skills • To learn effective communication and relationship skills

Treatment may include relaxation training, restructuring, and eliminating of negative

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64 automatic thoughts and dysfunctional attitudes.

Another treatment modality used for infertility is ACT (Haynes, 2004; Haynes et al. 2006). ACT encompasses both CBT and DBT, challenging thoughts and distortions while practicing mindfulness, distress tolerance, and emotion regulation. The goal of ACT is to develop “psychological flexibility.” The Core aspect of ACT involves four crucial client questions:

1. What do I value? 2. What is pulling or pushing me away from my values? 3. What action do I need to take now to push myself closer to my values? 4. How do I continue to move toward my values in the future?

ACT has also been applied specifically to infertility treatment. Peterson & Eifert (2011) describe ACT as especially pertinent to treating infertility stress by helping couples accept and come to terms with feelings of disappointment, failure, and inadequacy rather than continuing to engage in behavior designed to get rid of such emotional experiences (avoidance behaviors). They provide as an example of such avoidance behaviors not attending social situations where children may be present – which in turn contributes to social isolation. There may also be an avoidance of sexual intimacy that does not have the express purpose of reproduction, causing relationship stress. Addressing such behaviors is an important aspect of ACT.

Peterson & Eifert also state that ACT could help clients diminish judgmental thoughts and evaluations about their inability to conceive by learning to simply observe such evaluative thoughts, thus decreasing their believability. ACT uses acceptance strategies and cognitive defusion techniques (e.g., metaphors, mindfulness exercises) to teach clients to respond more flexibly to infertility-related thoughts and create distance between themselves and their internal experiences. For example, instead of trying to dispute or change thoughts such as “It's unfair that we can't have a baby,” clients are taught to acknowledge these as thoughts can simply be observed. Another key aspect of ACT with regard to infertility support is in helping couples to practice compassionate acceptance toward their experiences.

In addition to these therapeutic options, there has been an increase on online fertility support, such as through organizations such as Resolve (a national infertility organization) and through online message boards. These may present helpful options for clients who are unwilling to consider group treatment and who could benefit from a sense of shared experiences.

Chapter 5 Topics in Human Sexuality: Sexually Transmitted Diseases

Case Vignette

Marla is a 15-year-old high school sophomore. She has been sexually active since age 13 and has had multiple sexual partners. Although she tries to do the “responsible thing” by using

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65 protection, she has had unprotected sex at times, particularly when she has been drunk or high. Marla has recently been experiencing lower abdominal pain and foul smelling vaginal discharge and has noted that intercourse with her current boyfriend has been painful. She has her first gynecological examination and is dismayed to find that she has pelvic inflammatory disease (PID).

No discussion of human sexuality is complete without consideration of sexually transmitted diseases (STDs). Sexually transmitted diseases are infections that can be transferred from one person to another through sexual contact. According to the Centers for Disease Control and Prevention, there are over 15 million new cases of sexually transmitted diseases in the United States each year (CDC, 2015a). There are more than 25 varieties of STDs. Although HIV remains the most well known STD with approximately 40 million people are currently living with HIV infection, other common STDs include chalymidia, gonorrhea, genital herpes and genital warts.

Adolescents and young adults are at great risk for contracting an STD because of a variety of behavioral, biological, and cultural reasons (CDC, 2013). Prevalence estimates suggest that young people aged 15–24 years acquire half of all new sexually transmitted diseases and that 1 in 4 sexually active adolescent females have an STD, such as chlamydia or human papillomavirus (HPV).

Many STDs can have serious consequence, both physical and emotional. For example, some STDs can lead to pelvic inflammatory disease, pelvic inflammatory disease, which can cause infertility. Other STDs, such as HIV, can be fatal. On an emotional level, people with illnesses such as genital herpes, which is incurable, often feel like outcasts and shun relationships due to shame around the disease.

It is important for mental health professionals working with people of all ages to be aware of STDs, their symptoms, treatments and the difficulties surrounding them.

Objectives:

After finishing this chapter, the participant will be able to:

• Discuss Chlamydia including symptoms, complications and treatment • Define Pelvic Inflammatory Disease (PID) • Discuss gonorrhea, including symptoms, complications, pregnancy and treatment • Discuss syphilis, including stages, symptoms, complications, pregnancy and treatment • List the medical issues associated with HPV, as well as prevention and treatment of this virus • Describe the symptoms, psychological consequences and prevention of genital herpes • Discuss symptoms, diagnosis and treatment of pubic lice

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• Discuss HIV infection, including populations affected, transmission, symptoms and treatment • Describe the signs, symptoms and treatment of trichomoniasis • Discuss other genital infections • Describe the incidence and reasons for STDs among adolescents, pregnant women and men who have sex with men (MSM) and transgender men and women

Chlamydia

Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. 1,526,658 Chlamydial infections were reported to the CDC in 2015 (a large number of cases are not reported because most people with chlamydia are asymptomatic). Chlamydia is most common among young people. Almost two-thirds of new chlamydia infections occur among youth aged 15-24 (Torrone, Papp, & Weinstock, 2014).

Chlamydia is caused by the bacterium, Chlamydia trachomatis. The disease is particularly dangerous for women and can cause serious complications that result in irreversible damage. Men with Chlamydia infection in the urethra are said to have nongonoccal urethritis or NGU (Webmd, 2010).

Symptoms

Chlamydia is known as a "silent" disease because the majority of infected people have no symptom. When they do occur, symptoms usually appear within 1 to 3 weeks after exposure.

In women, the bacteria initially infect the cervix and the urethra. Women might have an abnormal vaginal discharge or a burning sensation when urinating. If the infection spreads from to the fallopian tubes, women may have lower abdominal pain, low back pain, nausea, fever, or bleeding between menstrual periods. Chlamydial infection of the cervix can spread to the rectum.

Men are also generally asymptomatic (only 50% experience symptoms). Those who do have signs may have a discharge from their penis, a burning sensation when urinating or burning and itching around the opening of the penis.

Complications/PID

The complications of Chlamydia are of particular concern for women. Because the disease is often asymptomatic, women may not be treated for the disease. In about 10-15 % of women with untreated infection, Chlamydia spreads to the uterus or fallopian tubes, causing pelvic inflammatory disease (PID). PID is also common in gonorrhea. Each year about one million women develop PID. PID can cause infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and

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67 chronic pelvic pain. Chlamydia may also increase the chances of becoming infected with HIV.

Treatment

Chlamydia is treated with antibiotics, most commonly Azithromycin or Doxycycline. Alternative antibiotic treatment is used for those with sensitivity to these drugs. It is important for partners to both be treated concurrently.

Gonorrhea

Gonorrhea (“the clap”) is the oldest STD on record. Symptoms of gonorrhea are described in the Old Testament. There has been a recent resurgence of this disease and the CDC estimates approximately 820,000 new gonococcal infections occur in the United States each year, and that less than half of these infections are detected and reported to CDC (CDC, 2015d).

Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply in warm, moist areas of the reproductive tract, including the cervix, uterus, fallopian tubes and urethra. Gonorrhea can also grow in the mouth, throat, eyes, and anus.

Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. Ejaculation need not occur for gonorrhea to be transmitted. The disease can also be spread from mother to baby during delivery.

Symptoms

People who are infected with gonorrhea may be asymptomatic. Most women are either asymptomatic or have mild symptoms. Symptoms can be mistaken for a urinary tract infection, and may include a painful or burning sensation when urinating, increased vaginal discharge, or bleeding between periods. Women with gonorrhea are at risk of developing complications from the infection, regardless of the severity of symptoms. Gonorrhea is a common cause of PID.

Men may also be asymptomatic. When symptoms do appear, they generally occur within five to eight days of infection but can take as long as 30 days. Symptoms include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Some men experience painful or swollen testicles. Gonorrhea can cause epididymitis, a painful condition of the ducts attached to the testicles causing infertility.

Symptoms of rectal infection include discharge, anal itching, soreness, bleeding, or painful bowel movements.

Additional Complications

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Gonorrhea can spread to the blood or joints, causing a potentially life threatening condition. People infected with gonorrhea can also more easily contract HIV

Pregnancy

Women who have gonorrhea during pregnancy have higher rates of miscarriage, infection of the amniotic sac and fluid, preterm birth, and preterm premature rupture of membranes (PPROM).

Gonorrhea can be transmitted to the baby during delivery, and can cause serious complications including blindness. Most states require that all babies be treated with medicated eye drops soon after birth as a preventive measure.

Treatment Gonorrhea is very treatable. Treatment generally involves either an injectible or oral antibiotic. A single dose is usually all that is required, but some antibiotics require longer courses. Ofloxacin, Cefixine, and Ceftriaxine are commonly prescribed.

Syphilis

Syphilis is a STD caused by the bacterium Treponema pallidum. It has been called "the great imitator" because so many of the signs and symptoms are indistinguishable from those of other diseases. Historically syphilis was also known as “the great pox.” It first appeared in Europe during the 1400s and became a pandemic by 1500.

According to the CDC, there were 74,702 reported new cases of syphilis in 2015 (CDC, 2015a). The group with the highest reported prevalence are men who have sex with men (MSM), accounting for 81.7% of all primary and secondary syphilis cases (CDC, 2015e).

According to the CDC (2015e), congenital syphilis (passed from pregnant women to their babies) continues to be a problem. During 2015, 487 cases of congenital syphilis were reported. Congenital syphilis rates were 8.0 times and 3.5 times higher among infants born to black and Hispanic mothers as compared to white mothers.

Although syphilis is less common than many of the other STDs, its affects are quite serious. It can cause sterility, and if left untreated result in damage to the nervous system and death.

Transmission

Syphilis is transmitted through direct contact with a syphilis sore. Sores can occur on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Syphilis can also be transmitted from pregnant women to their babies.

Symptoms

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Many people infected with syphilis do not have any symptoms for years, which is quite problematic given the serious complications that can ensure from leaving the disease untreated. Additionally symptoms of syphilis can often look like other diseases. For this reason, syphilis is sometimes called “The Great Pretender.”

Although transmission occurs contact with a syphilis sore (carriers in the primary or secondary stage these sores may not be evident. Transmission may occur from persons who are unaware of their infection.

The stages are:

• Primary Stage Marked by the appearance of a single sore (called a chancre), but there may be multiple sores. The time between infection and the start of the first symptom can range from 10 to 90 days (average 21 days). The chancre is generally firm, round, small, and painless, lasts 3 to 6 weeks, and heals on its own. However, if the syphilis is not treated, the infection progresses to the secondary stage.

• Secondary Stage This stage is characterized by skin rash and mucous membrane lesions. This stage typically starts with the development of a rash on one or more areas of the body. The rash generally consists of reddish brown spots both on the palms of the hands and the bottoms of the feet. Sometimes rashes associated with secondary syphilis are so faint they are barely noticeable. In addition an infected person may experience fever, swollen lymph glands, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.

• Late and Latent Stages. The late stages of syphilis can develop in about 15% of people who have not been treated. They can appear as long as 10–20 years after the person was first infected. In the late stages of syphilis, the disease may damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Signs and symptoms of this stage include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. The person may die in this stage of the illness.

Syphilis can invade the nervous system (neurosyphilis )at any stage of infection, and causes a wide range of symptoms varying from no symptoms at all, to headache, altered behavior, and movement problems that look like other neurologic diseases, such as Parkinson’s or Huntington’s disease.

Treatment

In its early stages syphilis is easy to cure. For a person who has had syphilis less than a year, treatment involves a single intramuscular injection of penicillin. Additional doses are needed to treat someone who has had syphilis for longer than a year. Penicillin (or another antibiotic for those who are allergic) will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

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People who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed.

HPV (Human Papilloma Virus)

HPV stands for human papilloma virus, and is the most common sexually transmitted disease. HPV is transmitted through genital contact, most often during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact.

Most people who contract HPV do not develop symptoms or health problems. But other, more aggressive strains of HPV can cause significant problems including:

12. Genital warts. Small warts in the genital area. Warts can appear within weeks or months after sexual contact with an infected partner, even if the partner has no signs of genital warts. Genital warts are not dangerous, but they can increase in number if left untreated.

13. Cervical cancer can be caused by untreated HPV. Women should receive regular screenings for cervical and other gynecological cancers.

14. Other HPV-related cancers include cancers of the vulva, vagina, penis, anus, and head and neck.

15. RRP. The HPV virus can cause warts to grow in the throat, a condition called recurrent respiratory papillomatosis or RRP. These warts can block airways, causing troubled breathing.

Prevention

Vaccines are effective protection against HPV. These vaccines are given in three shots, and are most effective prior to a person's first sexual contact.

• Girls and women: Cervarix and Gardasil protect females against the types of HPV that cause most cervical cancers. Gardasil also protects against most genital warts. Both vaccines are recommended for 11 and 12 year-old girls, and for females 13 through 26 years of age, who were not previously vaccinated

• Boys and men: Gardasil protects males against most genital warts. This vaccine is available for boys and men, 11 through 26 years of age.

• The CDC now recommends 11 to 12 year olds get two doses of HPV vaccine—rather than the previously recommended three doses—to protect against cancers caused by HPV. The second dose should be given 6-12 months after the first dose.

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Latex condoms also lower the risk of HPV infection as does limiting sexual partners.

Treatment

Generally people with HPV are treated for the symptoms of the disease, such as genital warts. Medications for warts include Podophyllin. Cryocautery can freeze warts. In harder to treat cases, laser therapy or surgical excision may be recommended.

Genital Herpes

Case Vignette

Jennifer is a 35-year-old woman who contracted genital herpes during college. She has struggled emotionally since contracting the illness and has generally avoided relationships, fearing that they could lead to sexual contact. The illness has caused severe emotional pain and distress.

Genital herpes is an STD caused by the herpes simplex viruses, most frequently type 2. Genital herpes infection is common in the United States. Herpes is passed through genital contact and can occur even when an infected partner does not have visible signs of the virus.

Genital herpes infection is common in the United States. CDC estimates that, annually, 776,000 people in the United States get new herpes infections. Over the past decade, the percentage of Americans with genital herpes has remained stable (CDC, 2015a). Of all STDs, genital herpes is one of the most devastating as there is no cure. Outbreaks of the disease are unpredictable, and have significant consequences on a person’s sexual freedom, frequency and spontaneity.

Infections are transmitted through contact with lesions, genital secretions or oral secretions. The herpes infection can also be shed from skin that looks normal. Generally, a person can only get herpes simplex 2 infection during sexual contact with someone who has a genital herpes simplex 2 infection.

Most individuals have no or only minimal signs herpes infection. Symptoms may appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender sores that may take two to four weeks to heal the first time they occur. Typically, another outbreak can appear weeks or months after the first, but it generally is less severe. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over the years.

Complications

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Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected.

Genital HSV can lead to potentially fatal infections in babies. If a woman has active genital herpes at delivery, a cesarean delivery is usually performed.

Treatment

There is no known drug that will kill HSV. Acylovir can be used to prevent or reduce recurring symptoms.

Prevention

The most effective prevention for genital herpes is abstinence from sexual contact, or a mutually monogamous relationship with an uninfected partner.

Although latex condoms reduce the risk of genital herpes, genital ulcers in both male and female genital areas can occur in areas that are not covered by condoms.

Persons with herpes should abstain from sexual activity with uninfected partners when they have lesions or other symptoms. Even if a person does not have symptoms he or she can still infect sex partners. Sex partners can seek testing to determine if they are infected with HSV.

Pubic Lice

Pubic Lice (Phthirus pubis,) are also called crab lice or "crabs," are parasitic insects found primarily in the pubic or genital area of humans. These lice can also be found in armpit hair and eyebrows. The primary age group infected by pubic lice are teenagers. Lice infestation is usually spread during sexual activity. Less commonly can be spread through contact with objects such as toilet seats, sheets, blankets, or bathing suits. Risk factors for public include having multiple sexual partners, sexual contact with an infected person and sharing bedding or clothing with an infected person. Symptoms The most common symptom of pubic lice is itching in the pubic area. The itching often intensifies at night). This itching may start soon after being infected with lice, or it may not start for up to 2 to 4 weeks after contact. Other symptoms include skin reaction that is bluish-gray in color, and in the genital area due to bites and/or scratching. Scratching the skin in this area could also result in irritation leading to a secondary infection. Treatment

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Public lice are very treatable using a prescription wash containing permethrin. Two of these washes are Elimite and Kwell. Following the wash, the person must comb the pubic hair with a fine-toothed comb to remove nits. Generally a single treatment is all that is necessary. In addition to this treatment, all clothing and linens should be thoroughly washed in hot water. Human Immunodeficiency Virus (HIV)

HIV or Human Immunodeficiency Virus is the retrovirus responsible for AIDS. HIV and AIDS remain a persistent problem for the United States and globally. While a great deal of progress has been made in preventing and treating HIV, there is still much to do. In 2015, 39,513 people were diagnosed with HIV. The annual number of new diagnoses declined by 9% from 2010 to 2014 (CDC, 2015b). This may in part be due to targeted HIV prevention efforts. Gay and bisexual men accounted for 82% of HIV diagnoses among males and 67% of all diagnoses. Heterosexual contact accounted for 24% of HIV diagnoses and six percent were attributed to injection drug use (CDC, 2015b).

Among younger people, minorities have been hard hit by HIV/AIDS. African Americans (45% of HIV diagnoses) continue to experience the greatest burden of HIV compared to other races and ethnicities. Hispanics/Latinos (24% of HIV diagnoses) are also disproportionately affected by HIV (CDC, 2015c).

Transmission

There are a number of possible routes of transmission for HIV.

1. Most commonly, HIV is spread by having sex with an infected partner. The virus enters the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex. Unprotected anal intercourse carries a higher risk than most other forms of sexual activity.

2. HIV can be spread among injection-drug users who share needles or syringes that are contaminated with blood from an infected person.

3. Women can transmit HIV to their babies during pregnancy, childbirth or breastfeeding. For women who are pregnant and HIV positive, doctors generally recommended anti-HIV medications to prevent babies from becoming infected.

4. HIV can spread through accidental needle sticks or contact with infected fluids. It is rare nowadays that HIV would be spread from contaminated blood products.

5. Other (rare) risk factors: a) Eating food that has been pre-chewed by an HIV-infected person. The contamination occurs when infected blood from a caregiver’s mouth mixes with food while chewing. The only known cases are among infants. b) Being bitten by a person with HIV. c) Contact between broken skin, wounds, or mucous membranes and HIV- infected blood or blood-contaminated body fluids.

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HIV cannot be spread by casual contact. HIV is not an airborne, water-borne or food-borne virus, and does not survive for very long outside the . Ordinary social contact such as kissing, shaking hands, coughing or sharing silverware does not result in the virus being passed from person to person.

Symptoms

There are typically a number of phases of HIV symptoms. There is a symptom-free period, a period of early infection. The disease may then progress to AIDs (acquired immune deficiency disorder).

Many people with HIV do not know they are infected. Symptoms may not occur immediately. Some people who are exposed to HIV do not show any signs of the illness for up to 10 years. In other cases people have flu-like symptoms within days of exposure, but these symptoms remit quickly. During this asymptomatic phase, the virus continues to multiply and infects and kills the cells of the immune system. The HIV virus destroys the cells that are the primary infection fighters, a type of white blood cell called CD4 cells. Although there are no symptoms associated with this stage of the disease, it is still contagious and can be passed along to others.

The later stage of the disease is AIDS. In this stage the body loses its ability to fight infections. People who have AIDS may contract a number of serious and potentially illnesses. These illnesses are known as opportunistic infections because they occur as a result of the weakened immune system. Opportunistic infections associated with AIDS include:

• Pneumonia • Toxoplasmosis • Yeast infections of the esophagus

The weakened immune state of AIDs can also lead to cancers. These cancers are difficult to treat and may be fatal.

• lymphoma in the brain • Kaposi’s sarcoma. This cancer was rare prior to AIDs and its incidence helped the CDC first identify AIDs as a medical condition.

Treatment

Treatment of HIV has progressed considerably since it was first recognized in the 1980s primarily due to newer antiretroviral therapies. HAART (highly active antiretroviral therapy) is a potent drug cocktail used to suppress the growth of HIV, the retrovirus responsible for AIDS. A combination of at least three drugs is the recommendation to keep the virus from replicating. The following medications are widely used in treatment (EMedicine Health, 2010):

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The following are the different classes of medications used in treatment.

Reverse transcriptase inhibitors (AZT/Retrovir): Inhibit the ability of the virus to make copies of itself and to keep the virus from multiplying.

Protease inhibitors (PIs): Interrupt virus replication at a later step in its life cycle, preventing cells from producing new viruses. When used in a cocktail they also reduce the chances that the virus will become resistant to medications.

Fusion and entry inhibitors: Newer agents that keep HIV from entering human cells.

Integrase inhibitors stop HIV genes from becoming incorporated DNA. This is a newer class of drugs recently approved to help treat those who have developed resistance to the other medications.

These medications are helpful in allowing a person who is infected with HIV to live longer and be less symptomatic. They do not cure HIV or AIDS.

Trichomoniasis

Trichomoniasis is a sexually transmitted disease that affects both women and men, although symptoms are more common in women. It is the most common curable STD in young, sexually active women. There are an estimated 7.4 million new cases each year.

Trichomoniasis is caused by the parasite, Trichomonas vaginalis. The vagina is the most common site of infection in women, and the urethra is the most common site of infection in men.

Symptoms

Most men with trichomoniasis do not have symptoms, but some may experience a mild irritation inside the penis, discharge, or burning after urination or ejaculation. Signs of the infection in women include a frothy, yellow-green vaginal discharge with a strong odor. The infection may cause discomfort during intercourse and urination, and irritation and itching of the vagina. Symptoms usually appear within 5 to 28 days of exposure.

Other Genital Infections

Vaginitis. Vaginitis is not considered an STD because it is not transmitted by sexual contact. Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. It is common among women, particularly those of college age. Vaginitis is generally caused by a change in the normal balance of vaginal bacteria or an infection. Vaginitis can also result

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76 from reduced estrogen levels after menopause.

The most common types of vaginitis are:

Bacterial vaginosis, which results from overgrowth of one of several organisms normally present in the vagina. Bacterial vaginosis is a common cause of vaginal discharge in women of childbearing age, is a polymicrobial clinical syndrome resulting from a change in the vaginal community of bacteria. Although BV is often not considered an STD, it has been linked to sexual activity. Women may have no symptoms or may complain of a foul-smelling, fishy, vaginal discharge. Women with bacterial vaginosis are also at a greater risk of contracting HIV and other sexually transmitted infections. In pregnancy, bacterial vaginosis can lead to serious pregnancy complications, including premature rupture of the membranes surrounding the baby in the uterus, preterm labor or premature birth.

Monilia or yeast infections, which are usually caused by a naturally occurring fungus called Candida albicans.

Vaginal atrophy (atrophic vaginitis), which results from reduced estrogen levels after menopause

Vaginitis symptoms may include a change in color, odor or amount of vaginal discharge, itching or irritation, pain during intercourse or urination or spotting. Treatment options depend on the type of vaginitis and may include prescription and OTC suppositories.

Special Populations

Adolescents

Most STDs are found in all age groups, with the exception of pubic lice, which is found primarily in adolescents. Compared to older adults, adolescents (10- to 19-year-olds) are at higher risk for acquiring STDs for a number of reasons, including limited access to preventive and regular health care and physiologically increased susceptibility to infection, failing to use barrier protection, and having concurrent multiple sexual partners. Approximately one in four sexually active teens contracts a sexually transmitted disease every year. An estimated half of all new HIV infections occur in people under age 25. Reported rates of chlamydia and gonorrhea are highest among females during their adolescent and young adult years, and many persons acquire HPV infection at this time (CDC, 2015b; Forhan, Gottlieb & Sternberg, et al., 2009).

All 50 states and the District of Columbia explicitly allow minors to consent for their own healthcare services for sexually transmitted diseases. No state requires that providers notify parents that an adolescent minor has received sexually transmitted disease services, except in limited or unusual circumstances (CDC, 2015b).

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Given these statistics, routine screening should be a part of good clinical care. With regard to prevention, education efforts, especially with regard to safe-sex guidelines are key. The CDC (2015) recommends that Health-care providers who care for adolescents and young adults should integrate sexuality education into clinical practice, particularly for all sexually active adolescents. Mason-Jones et al. (2016) looked at school-based sexual and reproductive health programs as an approach to reducing high-risk sexual behavior among adolescents. What was unique about this study was that the researchers were measuring biological data (e.g., contracting a sexually transmitted disease) rather than assessing adolescent knowledge about sexual risk behaviors.

While further study is needed, there is some evidence to suggest that school-based interventions may be helpful in reducing the incidence of sexually transmitted diseases in adolescents, especially when such programs are combined with measures such as access to condoms (Kann et al., 2015).

Safe Sex Guidelines

With all STDs, and particularly HIV, the most effective counsel is safe sex or abstinence. Hyde and DeLamater (2003) provide the following safe sex guidelines:

14. For those who choose to be sexually active, have sex only with one consistent stable sexual partner. 15. For those who are active with multiple partners, use a latex condom, which is the most effective protection against HIV. 16. If there is risk that a partner is infected, abstain from sex or use alternative forms of sexual expression that do not involve genital contact. 17. Abstain from being sexually active with people who have had multiple sexual partners. 18. Do not engage in anal sex if there is any chance that a partner has an STD. 19. If there is any chance of having been exposed to an STD, have a blood test to verify.

Additionally it is helpful to provide adolescents with information on recommended prevention vaccinations, such as HPV vaccinations (recommended routinely for females aged 11 and 12) and Hepatitis A and B vaccinations.

Pregnant Women

Sexually transmitted diseases can have severely debilitating effects on pregnant women and their babies. All pregnant women and their sex partners should be asked about sexually transmitted diseases and counseled about the possibility of such infections. The CDC recommends routine screening for most sexually transmitted diseases (e.g., chlamydia , gonorrhea , syphilis , HIV, hepatitis B and C) during the first prenatal visit for pregnant women under 25 who demonstrate risk factors for developing these illnesses. Depending on risk factors, clinicians may also recommend rescreening.

Overall risk factors include:

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• New or multiple sex partners • Sex partner with concurrent partners • Sex partner who has a sexually-transmitted disease Living in a high-morbidity area • Previous or coexisting sexually transmitted infection • Inconsistent condom use among persons not in mutually monogamous relationships • Exchanging sex for money or drugs

Specific to Hepatitis C:

• Past or current injection-drug use • Having received a blood transfusion before July 1992 • Receipt of unregulated tattoo • Long-term dialysis • Known exposure to Hepatitis C

Pregnancy Transmission and Results (CDC, 2015b)

Bacterial Vaginosis Associated with serious pregnancy complications, including premature rupture of the membranes surrounding the baby in the uterus, preterm labor, premature birth, chorioamnionitis (inflammation of the fetal membranes) and endometritis Chlamydia Untreated chlamydial infection has been linked to problems during pregnancy, including preterm labor, premature rupture of membranes and low birth weight. Newborns may become infected during delivery. Exposed newborns can develop eye and lung infections. Gonorrhea Lnked to miscarriages, premature birth and low birth weight, premature rupture of membranes, and inflammation of the fetal membranes. Newborns may become infected during delivery. Exposed newborns can develop eye and lung infections. Treat with antibiotics. Hepatitis B Can be transmitted to the baby during pregnancy. Infected (HBV) newborns also have a high risk (up to 90%) of becoming chronic HBV carriers themselves. Infants who have a lifelong infection with HBV are at an increased risk for developing chronic liver disease or liver cancer later in life. Hepatitis C Can be passed from an infected mother to her child during pregnancy. Infants born to HCV-infected women have been shown to have an increased risk for being small for gestational age, premature, and having a low birth weight. Herpes Simplex Virus Transmission may occur during pregnancy and after delivery. Symptoms appear shortly after birth and are serious. The baby may have clusters of fluid-filled blisters

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on their torso or around their eyes. Congenital herpes can cause seizures, encephalitis and in some cases death. Human HIV can pass from mother to child are during pregnancy, Immunodeficiency labor, and delivery, or through breastfeeding. Like adult Virus (HIV) HIV, acquired HIV can destroy specific blood cells that are crucial to helping the body fight diseases. Human Infection of the mother may be linked to the development Papillomavirus of laryngeal papillomatosis in the newborn—a rare, (HPV) noncancerous growth in the larynx.

Syphilis Can be transmitted from mother to baby during pregnancy. Syphilis has been linked to premature births, stillbirths, and, in some cases, death shortly after birth. Untreated infants that survive tend to develop problems in multiple organs, including the brain, eyes, ears, heart, skin, teeth, and bones. Trichomoniasis The female newborn can acquire the infection when passing through the birth canal during delivery and have vaginal discharge after birth. This is uncommon. Infection in pregnancy has been linked to premature rupture of membranes, preterm birth, and low birth weight infants.

Sexually transmitted diseases such as chlamydia, gonorrhea, syphilis, and trichomoniasis can all be treated and cured with antibiotics that are safe to take during pregnancy. Viral STDs, including genital herpes, hepatitis B, and HIV cannot be cured. In some cases these infections can be treated with antiviral medications or other preventive measures to reduce the risk of passing the infection to the baby.

Men Who Have Sex with other Men (MSM)

Men who have sex with other men (MSM) also have special risk factors with regard to sexually transmitted diseases and infections (CDC, 2015b). Like other groups discussed previously, safe sex practices greatly reduce risk in gay and bisexual men. Risk increases with sexual practices such as anal sex. Other factors that increase risk include anal sex, multiple sex partners (especially anonymous partners), seeking sex partners through the Internet and substance abuse (e.g., such methamphetamine). These risk factors are also present in heterosexual people who engage in these behaviors. Clinicians working in medical settings should inquire about symptoms consistent with common sexually transmitted infections, including urethral discharge, discomfort when urinating, genital and anal sores, rashes, and discharge and pain on defecation or during anal intercourse. ) The of any of these symptoms indicates the need to refer for diagnostic testing.

Increased risk for sexually transmitted diseases in MSM are as follows (CDC, 2015b):

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Gonorrhea Risk factors as previously indicated. Insertive oral sex has been associated with urethral gonorrhea acquisition (x pharyngeal gonorrhea). Rectal gonorrhea and rectal chlamydia prevalence rates among MSM were 5.4% and 8.9%, respectively. MSM with new HIV infection diagnoses are more likely to receive a diagnosis of asymptomatic gonorrhea. Hepatitis A, B and C Testing of all strains of hepatitis recommended for all MSM. Vaccination against hepatitis A and B is recommended for all MSM in whom previous infection or vaccination cannot be documented. Sexual transmission of hepatitis C can occur, especially among MSM with HIV infection. HIV Risk remains high, particularly in males of African American and Hispanic descent. Risk factors include either receptive/insertive anal sex without a condom, having another STD, having sex with anonymous partners without a condom, and using methamphetamines or drugs that enhance sexual performance. The CDC recommends routine HIV screening for all MSMs that are sexually active (regardless of condom use). HPV Remains highly prevalent in MSM. The HPV vaccination is recommended routinely for MSM (through age 26). Syphilis (primary Approximately two thirds of the cases in MSM. Risk factors and secondary) include syphilis secondary to acute HIV infection, substance abuse (e.g., methamphetamine), having multiple anonymous partners, and seeking sex partners through the Internet.

Transgender Men and Women

Transgender people present a diverse picture with regard to sexual orientation and practices, but are a group that needs screening for a number of sexually transmitted infections.

Much of the research related to disease risk among transgender people has almost focused on transgender women (i.e., male-to-female transgender people). Among transgender women, the incidence of sexually transmitted diseases, particularly HIV, continues to be high. Herbst, Jacobs, Finlayson et al. (2008) in their review, estimate the prevalence of HIV in the United States is 27.7% among all transgender women and 56.3% among black transgender women. This also appears to be an issue globally. It is important that providers be aware of patient’s physically anatomy and sexual practices in order to properly counsel transgender women about risk. Because many transgender women retain a functional penis, they might engage in insertive oral, vaginal, or anal sex with men and women, making risk factors for all sexually transmitted diseases similar to those outlined earlier in this material.

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Transgender men also have a variety of sexual orientations and have sex with various types of sexual partners. This variability makes it difficult to fully assess risk of sexually transmitted disease among this group. While more research is needed to fully understand this, preliminary research suggests that this may be an underserved group in terms of prevention efforts. Sevelius (2009) conducted qualitative (n = 15) and quantitative (n = 45) research with a small sample of transgender men. The researcher focused on risk behaviors, protective strategies, and perceptions of the impact of transgender identity on sexual decision-making among trans MSM. Many participants reported inconsistent condom use during receptive vaginal and anal sex with non-trans male partners. HIV prevalence was reported to be 2.2%. Risk factors included barriers to sexual negotiation including unequal power dynamics, low self-esteem, and need for gender identity affirmation. Protective strategies included meeting and negotiating with potential partners online. Sevelius concluded that prevention programs must tailor services to include issues unique to trans MSM and their non-trans male partners.

Chapter 6 Topics in Human Sexuality: Paraphilias and Paraphilic Disorders

Case Vignette Carl V., age 20, entered therapy at the urging of his wife, Melissa. Melissa has been increasingly concerned with Carl’s inability to become sexually aroused by “traditional” sexual foreplay. This has been a change in their relatively young marriage. Carl has asked for her to wear various shoes during sex, and while that had not initially been that alarming, she was concerned when she caught him masturbating with a pair of her heels.

"Human sexuality" refers to people's sexual interest in and attraction to others. It concerns the capacity to have erotic feelings and experiences. Sexuality may be expressed in many ways, including through: thoughts and fantasies, desires, beliefs, attitudes, behaviors and practices (Boundless). As the case above illustrates, human sexuality may involve a range of behaviors, and also varies from culture to culture. It is hard to define what type of sexual expression is “acceptable” and what is “deviant.” Human sexuality can be understood as part of the social life of humans, governed by implied rules of behavior.

Researchers often look to religion, culture, and the legal system to define “normal” sexual behavior. One of the first to write about atypical sexual behaviors (sexual addiction), Mark Schwartz (1996) defines atypical sexual behavior as sexual fantasies and activities that are not commonly practiced by most people and may cause adverse physical, emotional, and social consequences. Such behaviors can range from mild, occasional behaviors, to more severe and frequent. From a clinical perspective, there has been some effort to define atypical sexual behavior under the umbrella of the sexual paraphilias.

The term “paraphilia” was first coined by Wilhelm Stekel in the 1920s, and expanded upon by sexologist John Money (1993). Money used the term paraphilia to indicate unusual sexual interests. There is some degree of controversy surrounding the label of a “paraphilia,” as it indicates that certain behaviors are somehow deviant (Moser &

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Kleinplatz, 2005) when in fact they may be just at different ends of the spectrum. An example of a behavior once considered a paraphilia but now no longer classified as a psychiatric disorder, is homosexuality. Similarly there has been a shift in how we understand concepts related to gender and gender identity.

The term paraphilia was first introduced into DSM-III. This replaced the DSM-II term sexual deviation, “because it correctly emphasizes that the deviation lies in that to which the person is attracted” (Mann, Hanson & Thornton, 2008). Through DSM-IV-TR the term paraphilia referred to disorders of atypical sexual arousal, however, there was no term was available to indicate nonpathological, atypical sexual interests.

DSM 5 has changed the definition of paraphilias and introduced the term “paraphilic disorder.” Paraphilias involve a persistent, intense, atypical sexual arousal pattern, independent of whether it causes any distress or impairment, which, by itself, would not be considered disordered. The intent of this change is to reduce stigma by clarifying that atypical sexual arousal patterns are not evidence of psychopathology (First, 2014). The revised definition of paraphilia is quite broad and there are many potential paraphilias.

Paraphilic disorders, on the other hand, are “intense and persistent” and also preferential sexual interests. Paraphilic disorders cause distress or impairment to the individual or is one in which sexual satisfaction entails personal harm, or risk of harm, to others. This distinction was made in an effort to identify those sexual behaviors and interests that are of clinical significance. With the change, some sexual behaviors may be classified as paraphilic but not disordered.

The DSM 5 specifically identifies eight paraphilic disorders : voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorders.

This chapter will describe sexual paraphilias including their etiology, expression and treatment.

Educational Objectives 1. Describe sociocultural aspects of sexually atypical behaviors, including cultural views of paraphilias. 2. Discuss the development of atypical sexual behavior. 3. Define fetishism and list common fetish objects. 4. Discuss transvetism and its features, including why it is considered a fetish. 5. Define exhibitionism and list characteristics of exhibitionists. 6. Define frotteriusm and list characteristics of frotterists. 7. Discuss voyerusim and the range of normal versus deviant behaviors. 8. Discuss the proposed DSM-V diagnosis, hypersexual disorder. 9. Discuss the characteristics of sadism and masochism. 10. Define asphyxiophilia and list common features of the disorder. 11. Compare and contrast treatment approaches.

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12. Discuss medications useful in treating paraphilas.

Sexuality Across History and Cultures

History

In looking at sexual deviance, it is first important to consider the issue of history and culture. While it is difficult to know entirely how early cultures viewed sexuality, there have been a number of historical shifts that are believed to influence views of sexuality. These include:

• The shift from primarily agricultural communities to more urban ones, resulting in the need to limit population growth

• The advent of patriarchal societies and differing sexual expectations for men and women

• The sexual revolution of the 1920s (primarily limited to writers and artists including F. Scott Fitzgerald, Edna Saint Vincent Millay, and Ernest Hemingway)

• Publication of Sexual Behaviour in the Human Male followed by Sexual Behaviour in the Human Female (Kinsey). These books tackled such controversial topics such as the frequency of homosexuality, and the sexuality of minors aged two weeks to fourteen years

• In 1953 Hugh Heffner stared Playboy magazine and in 1960 opened the first Playboy Club; The sexual revolution of the 1960s (and first birth control); beginnings of the Women’s movement.

• ’s publication of Human Sexual Response in 1966

• Beginning in San Francisco in the mid-1960s, a new culture of "free love" emerged. Hippies preached the beauty of sex, often with multiple partners. This continued until the 1980s when knowledge of AIDS was publicized

• The Gay Rights movement began in 1969 and brought sexual intimacy between same sex partners more to the forefront

• By the 1970s the majority of Americans had experienced premarital sex. In 1973, the landmark Roe vs Wade politicized sex

• The 1980s saw a split in feminism between anti-pornography feminists and pro-sex feminists, who railed against censorship of any kind. In 1986 Surgeon General Edward Koop, in speaking about the AIDS epidemic, advocated for widespread sex education in schools. Sexuality was also widely seen in music videos.

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• In the 1990s sexual education in schools became widespread. Two distinct approaches were seen, both based on the idea of postponing sexual intercourse: abstinence-until-marriage, limits instruction to why young people should not have sex until they are married and balanced and realistic sexuality education, encourages students to postpone sex until they are older and to practice safer sex when they become sexually active. The number of teens having sex actually decreased during the 1990s (Crimons, 1998).

• The 2000s has shown an increase in sexual behavior, especially among youth, with casual “hook ups” and sexualized behavior. Many experts are concerned that this behavior is harmful to teens (Pesta, 2013). In 2015, Same Sex Marriage was legalized by a Supreme Court Ruling (Obergefell v. Hodges) in a 5-4 ruling, a decision that evidences increased openness to lesbian and gay relationships and sexual expression.

Culture

Cultures define and describe what is normal within the culture and what is abnormal or deviant. Definitions of normality, then, vary across cultures and are influenced by a many factors, including religion, media, and laws. A taboo is a strong social prohibition or ban relating to any area of human activity or social custom that is forbidden based on moral judgment or religious beliefs. There are many taboos related to sexuality, as demonstrated by the following training material. Some taboos, such as pedophilia, are also prohibited by law and may lead to strict penalties when such lines are crossed. Other taboos result in embarrassment and shame for the one breaking the taboo.

Researchers Burgha et. al. (2010) have used culture to look at sexual paraphilias. They describe cultures as either sex-positive, meaning sexual acts are seen as important for pleasure, or sex-negative, meaning that sexual acts are seen as only as for procreative purposes. U.S. culture would be considered a sex-positive culture overall.

Sexually Healthy Behavior

The World Health Organization (WHO) has developed a definition of sexually healthy/typical behavior, which provides a solid foundation for mental health professionals (WHO, 2002). They describe healthy sexuality as an approach to sexuality founded in accurate knowledge, personal awareness, and self-acceptance, in which one’s behaviors, values and emotions are “congruent and integrated within a person’s wider personality structure.” This definition describes “the ability to be intimate with a partner, to communicate explicitly regarding sexual needs and desires, and to be sexually functional, to have desire, become aroused and to attain sexual fulfillment.” Also of note is that healthy sexuality involves acting “intentionally and responsibly” and “having the ability to set appropriate sexual boundaries.”

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Sexual paraphilias, as defined by DSM 5, by their nature are antithetical to the definition above. These disorders generally limit sexual intimacy, skirt the bounds of sexual boundaries or involve actions that are solitary rather than partnered.

The Development of Atypical Sexual Behavior

While there are many possible explanations for sexually atypical behaviors, experts from various schools of thought have historically sought to explain sexual paraphilias. Such explanations typically fall into one of the following categories (or involve a combination of these approaches).

Psychodynamic Perspective From a psychodynamic perspective, sexual variations are a defense mechanism that enables people to avoid the anxiety of engaging in more normative sexual behavior and relationships (Comer, 2009). In this schema, a person’s sexual development is generally quite immature. An example of this approach would be that the view of sexual exhibitionism is as a defense against castration anxiety.

Behavioral Perspective/Learning Theory The behavioral perspective theorizes that abnormal sexual behavior is a conditioned response. The person learns to become aroused in a way that deviates from sexual norms. Carl’s shoe fetish, for example, may have started as a teen when he masturbated to a DVD of a provocative woman wearing high heels.

Developmental Approach Developmental approaches look at early factors that influence the development of atypical sexual behaviors (Kafka, 2000). Such factors include childhood sexual abuse, being exposed to sexuality at an early age (including pornography), or family pathology related to sexuality. Psychosexual development becomes hindered by these experiences. An example of this would be that a woman who is sexually abused may become fearful of sexual experiences, or conversely, may become sexually promiscuous (Sanderson, 2006).

Link to ADHD A childhood history of attention-deficit/hyperactivity disorder (ADHD) is also thought to increase the likelihood of developing a sexual paraphilia. The reason for the connection is not yet known, but researchers at Harvard have discovered that patients with multiple paraphilias have a much greater likelihood of having had ADHD as children than men with only one paraphilia (Encyclopedia of Mental Disorders, n.d.).

Sexual Paraphilas in DSM 5

Sexual paraphilas included in DSM 5 are: voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorders. The following section will discuss each of these disorders.

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Voyeuristic Disorder (Formerly Voyeurism)

Case Vignette: Thomas, a 24-year-old male was arrested after being caught masturbating outside of a neighbor’s window. He revealed to the arresting officer that he found it arousing to watch his neighbor undress and could not help but masturbate because she was so “hot.” This is the third time that police have responded to a call involving Thomas. When one of the officers jokingly said that Thomas should “ask for her number,” he recoiled disgustedly, stating that he would never do that.

Formerly known as Voyeurism in DSM-IV, Voyeuristic Disorder (in popular vernacular, a “peeping Tom”) refers to having recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. The person being considered for this disorder, in some way, has acted on these urges towards a nonconsenting person or the sexual fantasies/urges cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. There is often an element of risk associated with the act of observing the other person. The condition must also have been present for at least 6 months.

While the desire to watch others in sexual situations is not uncommon, the extreme to which this situation is disruptive is what makes it a clinical disorder. As discussed earlier, situations in which voyeurism occurs often involve some kind of risk, such as the possibility of exposure. For example, people would not be considered to have voyeuristic disorder if they were sexually excited by going to an exotic dance club. As in the case vignette, voyeurs generally do not seek to have sexual contact or activity with the person being observed.

Voyeurism usually begins during adolescence or early adulthood. When voyeurism becomes pathologic, those with the disorder may spend considerable time seeking out viewing opportunities, often to the exclusion of important life responsibilities or becomes disruptive in other ways, such as legal entanglements.

Up to 12% of males and 4% of females may meet clinical criteria for voyeuristic disorder. Voyeurism is considered to be the most common of law-breaking sexual behaviors (Raymond & Grant, 2008). There are several risk factors for Voyeuristic Disorder. Acts of voyeurism (that does not cause problems/distress) is considered as a precondition for Voyeuristic Disorder. According to DSM 5, other environmental risk factors are childhood sexual abuse, hyper sexuality, and substance abuse. People diagnosed Voyeuristic Disorder may also meet criteria for hypersexuality and other paraphilic disorders, especially exhibitionistic disorder. Depression, anxiety, attention deficit, anti-social behaviors, hyper sexuality, conduct and personality disorders, and bipolar disorder are also commonly comorbid.

Many people with voyeuristic disorder do not seek counseling unless mandated to do so or when it becomes otherwise disabling. Treatment for voyeuristic disorder may involve a

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87 combination of therapy and medication. Behavior therapy is the most common form of treatment, with the goal of helping the individual learn to control the impulse to watch non- consenting people and achieve sexual gratification in other ways. SSRIs may also be prescribed to inhibit sexual impulsivity. In more severe cases, prescribers may choose antiandrogen drugs to lower testosterone levels.

Exhibitionistic Disorder (Formerly Exhibitionism) Case Vignette: Lewis R., a 17-year-old is seeking counseling at the urging of his parents. They are concerned to have received a phone call from a neighbor, accusing Lewis of exposing himself to a 13-year-old girl. Lewis had initially denied that he had done so, but later admitted that he had done so previously. He felt as if he “couldn’t stop.”

The key feature of exhibitionism is intense, recurrent and sexually arousing fantasies involving the exposure of the individual's genitals. Colloquially referred to as “flashing,” the individual exposes his or her private body parts to another person. The exhibitionist does not typically initiate any type of sexual contact with the person to whom they may expose themselves, but may masturbate during the act of exposing themselves. Some exhibitionists are aware of a conscious desire to shock or upset their target; while others fantasize that the target will become sexually aroused by their display.

Most people who have exhibitionism do not meet the clinical criteria for a paraphilic disorder (i.e., exhibitionistic disorder), which requires that a person's behavior, fantasies, or intense urges result in clinically significant distress or impaired functioning or cause harm to others (which in exhibitionism includes acting on the urges with a nonconsenting person). The condition must also have been present for at least 6 months. Exhibitionists may masturbate while exposing or fantasizing about exposing themselves to others. About 30% of apprehended male sex offenders are exhibitionists. They have the highest recidivism rate of all sex offenders; about 20 to 50% are re-arrested.

Males who engage in exhibitionism typically begin the behavior prior to age 18. Onset is usually during adolescence; occasionally, the first act occurs during preadolescence or middle age. People who engage in exhibitionism may also be shy, or feel inadequate about their sexuality (Crooks & Bauer, 2002; Levine, 2000). About 2 to 4% of men meet criteria for exhibitionistic disorder. Few females are diagnosed with exhibitionistic disorder. This is an example of cultural influence, as exhibitionistic behavior is not seen as atypical in females and is actually sanctioned in the media and other venues.

While many people with exhibitionistic disorder are married, the marriage is often troubled by poor social and sexual functioning, including sexual dysfunction.

Personality disorders and conduct disorder may be comorbid conditions.

There are a number of theories about the origins of exhibitionism (Encyclopedia of Mental Disorders, n.d.). They include:

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Biological theories. These theories state that imbalances in testosterone increase the susceptibility for males to develop exhibitionism. Some medications used to treat exhibitionists are given to lower testosterone levels.

Developmental theories. History of emotional abuse in childhood and family dysfunction are both significant risk factors in the development of exhibitionism.

Head trauma. There are a small number of documented cases of men becoming exhibitionists following traumatic brain injury without previous histories of sexual offenses.

Treatment for exhibitionistic disorder may include therapy, support groups, and medication (SSRIs). Some individuals with this disorder are prescribed antiandrogen drugs, particularly in the case of sex offender status.

Frotteuristic Disorder (Formerly Frotteurism) Frotteurism refers to intense, recurrent fantasies of, and/or actual touching and rubbing the genitalia against a non-consenting person, in association with sexual arousal (Comer, 2009). The behavior usually occurs in crowded places, public places. Most commonly a man rubs his penis against a woman’s buttocks or legs (Crooks &Bauer, 2002) or may touch a victim’s breasts. The person engaging in the behavior often fantasizes about having an exclusive relationship with the person he is touching.

To meet criteria for frotteuristic disorder, symptoms must have been present for at least 6 months and the individual must experience significant distress or negative impact on functioning. The diagnosis of frotteuristic disorder can occur without having followed through with touching behaviors as long as sufficient distress regarding impulses is noted.

People who engage in frotteurism are generally males between the ages of 15 and 25. Initial symptoms of touching/fantasies to touch may begin as early as late adolescence. It has been estimated that as many as 30% of adult males may have engaged in frotteuristic acts, and 10-14% of men diagnosed with paraphilic disorders also meet the diagnostic criteria for frotteuristic disorder. While it is known that frotteuristic disorder is far more prevalent among men than women, with acts most commonly committed against women, specific statistics regarding female diagnoses are unavailable (The American Psychiatric Association, 2013).

Frotteuristic disorder is known to be comorbidly diagnosed with other paraphilic disorders, including hypersexuality, exhibitionistic disorders and voyeurism, as well as conduct disorders, antisocial personality disorder, mood disorders (including depression, bipolar, and anxiety disorders) and substance abuse. It is also important to note that while conduct disorder, antisocial personality disorder, and substance abuse disorders may involve isolated instances of frotteuristic behaviors, these rarely qualify for diagnosis of frotteuristic disorder, particularly if the behavior only occurs during intoxication (The American Psychiatric Association, 2013).

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Individuals with frotteuristic disorder often have feelings of sexual and social inadequacy (Levine, 2000) and find this type of behavior to be safe. Although there is not consensus on what causes frotteurism, an often cited theory is the behavior stems from an initially random or accidental touching of another's genitals that the person finds sexually exciting. Successive repetitions of the act tend to reinforce the behavior.

Frotteurism is a criminal act in most jurisdictions. It is generally classified as a misdemeanor. As a result, legal penalties are often minor and repeated offenses are likely without some other sort of intervention.

Treatment of frotteuristic disorder focuses on the reduction of sexual urges and behaviors through behavioral therapy, used to identify triggers and redirect behavior, and psychopharmaceutical intervention using SSRIs or antiandrogen drugs (The American Psychiatric Association, 2013).

Sadism and Masochism Case Vignette Marla M., age 20, has been in treatment for childhood abuse. She recently revealed to her trusted therapist that many of her sexual liaisons involve meeting men online for the purpose of engaging in masochistic behavior, such as being spanked or humiliated. She recognizes that this likely stemmed from her past, but this insight has not allowed her to stop engaging in the behaviors.

A sadist is a person who derives sexual satisfaction from inflicting pain, suffering or humiliation on another person. The pain, suffering, or humiliation inflicted on the other person may be either physical or psychological in nature. The person receiving the pain may or may not be a willing partner. When the sexual activity is consensual, the behavior is sometimes referred to as sadomasochism.

The name “sadism” derives from the name of the historical character the Marquis de Sade, a French aristocrat who published novels about these practices. Sadistic acts generally reflect a desire for domination of the other person. This can include behavior that is not physically harmful but may be humiliating to the other person (such as being urinated upon). Some acts of sadism may be very harmful. Examples of sadistic behaviors include restraining or imprisoning the partner, spanking, administering electrical shocks, biting, urinating or rape.

A masochist is a person who is sexually aroused by experiencing pain. The term “masochism” is named after Leopold von Sacher-Masoch, who was a masochist and wrote novels about his masochistic fantasies. An individual with sexual masochism often experiences significant impairment or distress in functioning due to masochistic behaviors or fantasies. Sadistic fantasies often begin in childhood and the onset of sexual sadism typically occurs during early adulthood. These behaviors are generally chronic and continue until the person seeks treatment. Often people with sadistic fantasies do not seek treatment due to the social unacceptability of these thoughts.

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Masochistic acts include being physically restrained or receiving punishment or pain. Psychological humiliation and degradation can also be involved. Masochistic behavior can occur in the context of a role-play. Masochists may also inflict the pain on him or herself, such as through self-mutilation. Like with sadism, masochistic fantasies often begin in childhood and the onset of sexual masochism typically occurs during early adulthood. These behaviors are generally chronic and continue until the person seeks treatment.

Sadiomaschistic behavior is the consensual use of sadistic and masochistic behaviors. Bondage and discipline refers to the use of physically restraining devices or psychologically restraining commands as a central part of sexual interaction. Dominance and submission refers the use of power consensually given to control the and behavior of the other person (Hyde & DeLameter, 2010).

Sexual masochism is form of paraphilia, but most people who have masochistic interests do not meet clinical criteria for a paraphilic disorder, which require that the person's behavior, fantasies, or intense urges result in clinically significant distress or impairment. The condition must also have been present for at least 6 months.

There is not consensus on the causes of sadism and masochism. There is a small body of research that has looked at historical factors in men and women with sadistic/masochistic fantasies and has found a link to early sexual abuse (see for example Messman & Long, 1999).

With asphyxiophilia is a specifier given to the disorder name if the individual engages in the practice of achieving sexual arousal related to restriction of breathing The person who engages in asphyxiophilia may employ a variety of techniques such as a pillow against the face, a rope around the neck or a plastic bag over the head. This is dangerous behavior and can lead to death.

Pedophilic Disorder Pedophilic disorder is characterized by recurrent, intense sexually arousing fantasies, urges, or behaviors involving prepubescent or young adolescents (usually less than or equal to 13 years old). Pedophilic disorder is diagnosed only when The person is at least age 16 years and at least 5 years older than the child or children in that is the object of sexual interest.

Sexual offenses against children constitute a significant proportion of reported criminal sexual acts. It is important to note that legal criteria may be different from psychiatric criteria. Predatory pedophiles, many of whom have antisocial personality disorder, may use force and threaten to physically harm the child or the child’s pets if the abuse is disclosed.

Most pedophiles are male. Attraction may be to young boys, girls, or both. In most cases pedophiles prefer opposite-sex to same-sex children (2:1 ratio). The adult is often known to the child and may be a family member, stepparent, or a person with authority. Looking or

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91 touching seems more prevalent than genital contact. Pedophiles may be attracted only to children (exclusive) or also adults (nonexclusive).

Sexual interest in children is a well-known risk factor for sexual recidivism (Stephens et. al., 2017).

Treatment generally includes therapy, treatment of comorbid disorders and medication. CBT may target cognitive distortions. Ward and Keenan suggest that child sexual offenders are distinguished by their specific content including the belief that adult’s sexual activity with a child is not detrimental to the minor, that it is neutral or even rewarding to him/her.

SSRIs may help control sexual urges and fantasies. They also decrease the sex drive and may cause erectile dysfunction. Additionally long-acting gonadotropin-releasing hormones (GnRH, ie, medical castration) or antiandrogens may also be used.

Fetishistic Disorder (Fetishism) The case vignette provided at the start of this training material provides an example of fetishism. Fetishism is the use of an inanimate object or a specific part of the body for physical or mental sexual stimulation. Often the person masturbates while touching, smelling or rubbing the fetish object. In some cases, the person may ask their partner to wear the object while engaging in intercourse. In a media fetish, the material out of which an object is made is the source of arousal. In a form fetish the object and shape are important. (Hyde & DeLamater, 2010).

Some common fetish objects include shoes (particularly those with heels), women’s lingerie, rubber items and leather. People may also have fetishes that involve particular body parts, such as feet or breasts. Fetishes are an example of behavior in which some aspects are normative, and that deviation occurs on a continuum. Many men, for example, are aroused by sexy lingerie, but the primary object of their desire is the female wearing the lingerie. In fetishism, the object of desire is the lingerie. Fetishes generally develop in adolescence. A common view of fetishism is found in learning theory and is that fetishes are the result of classical conditioning, in which there is a learned association between the fetish object and sexual arousal and orgasm (Hyde & DeLamater, 2010).

Fetishistic disorder refers to recurrent, intense sexual arousal from use of an inanimate object or from a very specific focus on a nongenital body part (or parts) that causes significant distress or functional impairment. For the most part, fetishes are harmless and do not upset others. It is unusual that people seek therapeutic intervention without the urging of others, such as a partner, or unless they become disturbed by the social isolation associated with some fetishes. Treatment of fetishism could include psychotherapy, drugs, or both. SSRIs have been used with limited success in some patients who request treatment.

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Transvestic Disorders (formerly Transvetism) Case Vignette: Mary G. is a lesbian woman. She has always identified more with the masculine, strong role in her relationships with other women. She often dresses in tight blue jeans and leather jackets and has been misidentified as a young man as times. Mary believes that her fashion choices are not sexually motivated; it’s just what she prefers. Is Mary a transvestite?

Transvetism is a type of paraphilias that refers to dressing as a member of the opposite gender in order to achieve sexual gratification. Like many of the paraphilias, there is a great deal of variability in the act of cross-dressing, and it is not necessarily considered a clinical disorder in all cases. In the case vignette, for example, Mary would not be considered to have a clinical disorder, because she does not gain sexual satisfaction from the act of cross- dressing, nor does she fantasize about cross-dressing. Similarly, those who cross-dress for entertainment purposes, such as male homosexuals (drag queens) are not considered to have a clinical disorder, nor would entertainers such as Robin Williams or Dustin Hoffman, who have appeared in movies in female roles. Conversely transvestic disorder is transvestism that causes significant distress or significant functional impairment.

The essential feature of transvetism, then, is recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. These fantasies or behaviors cause clinically significant distress or impairment. Since the person derives sexual gratification from cross-dressing, an clothing is the object of sexual desire, transvestism is considered a to be a type of fetish. The behavior occurs almost exclusively in males.

Case Vignette: George M., a happily married father of two, would occasionally, and with his wife’s knowledge, dress in her clothing. He admits that he finds the behavior to be arousing, and enjoys fantasizing about how and when he can do so. His wife is not concerned about the fantasies, and feels that George is a good husband and father.

Usually the male with transvetism keeps a collection of female clothes that he intermittently uses to cross-dress. While cross-dressed, he generally masturbates, imagining himself to be both the male and the female object of his sexual fantasy. Some males with this disorder wear a single item of women's clothing, such as a bra or underwear beneath their masculine attire. Others dress entirely as females and wear makeup. When not cross-dressed, males with Transvestic Fetishism are generally unremarkably masculine, and are heterosexual, although sexual contacts may be limited and he may occasionally engage in homosexual acts.

In a large-scale study of transvestites, Docter and Prince (1997) surveyed one thousand and thirty-two male cross-dressers. Eighty-seven percent described themselves as heterosexual. All except 17% had married and 60% were married at the time of this survey. Of the present sample, 45% reported seeking counseling. The study also attempted to distinguish between nuclear (stable, periodic cross-dressers) and marginal transvestites (more transgendered, please see section on gender identity disorder).

Research indicates that there are four basic motivations for transvestism (Talamini, 1982):

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16. Sexual arousal 17. Relaxation: taking a break from male roles and pressures and connecting to emotionality 18. Role playing: satisfaction in being able to pass as a woman 19. Adornment: sense of being “beautiful”

Families of transvestites are often accepting of this sexual deviation (Talamini, 1982), and again, appear quite normative in other ways. Many cross-dressers do not present for treatment. Those who do are usually brought in by an unhappy spouse, referred by courts, or self-referred out of concern about experiencing negative social and employment consequences. Some cross-dressers present for treatment of comorbid gender dysphoria, substance abuse, or depression.

Social and support groups for men who cross-dress are often very helpful. Therapy, when indicated, is aimed at self-acceptance and modulating risky behaviors. Later in life, sometimes in their 50s or 60s, cross-dressing men may present for medical care because of gender dysphoria symptoms and may then meet diagnostic criteria for gender dysphoria..

Counseling for Sexually Atypical Behavior Treatment for sexually variant behaviors is complex. There is often a great deal of secretiveness and shame around the atypical sexual behaviors. Some question whether counseling for sexual variations/paraphilas is necessary. The indicator is specific distress to self or others is helpful to consider. Thus, paraphilic disorders are more likely to be targets of treatment than paraphilias.

As discussed previously, the etiology of paraphilias is unknown, but it is probably a learned behavior. Paraphilias occur primarily in males with an average onset between ages 8 and 12. They are lifelong conditions. Treatment is focused on decreasing the arousal to the deviant sexual behavior, rather than extinguishing the sexual orientation.

Intake/Assessment The evaluation of an individual with problematic sexual behavior includes a clinical interview that elicits a detailed sexual history, including childhood exposure to sexual acts, details about sexual partners, and an assessment of sexual functioning such as masturbation patterns. An overall medical and psychiatric history is also helpful to identify comorbidity or medical conditions that mimic paraphilias (traumatic brain injuries, dopaminergic agents). Paraphilias may co-occur or change from one to another (known as “crossing-over”).

Individual Therapy: Cognitive behavioral methods, including relapse prevention strategies, appear the most effective. CBT programs include (Abel et. al., 1992). The goal of CBT is to modify the person’s sexual deviations by addressing distorted thinking patterns and making them aware of the irrational justifications that lead to their sexual variations.

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1. Behavior therapy to reduce inappropriate sexual arousal and enhance normal sexual arousal. 2. Social skills training. 3. Modification of thought distortions: challenging justifications for sexually atypical behavior. 4. Relapse prevention: avoidance of control of triggers to behaviors; helping the person to control the undesirable behaviors by avoiding situations that may generate initial desires.

In covert sensitization, the person’s negative sexual variation is paired with an unpleasant stimulus in order to deter them from repeating the act. This approach has been proven effective in cases of pedophilia and sadism.

In orgasmic reconditioning, the person is conditioned to replace fantasies of exposing himself with fantasies of more acceptable sexual behavior while masturbating. To employ this approach, the person is told to masturbate to his or her typical, less socially acceptable stimulus. Then, just prior to orgasm, the person is directed to concentrate on a more acceptable fantasy. This is repeated at earlier times before orgasm until, soon, the patient begins his masturbation fantasies with an appropriate stimulus.

Group therapy. This form of therapy is used to get patients past the denial that is frequently associated with paraphilias, and as a form of relapse prevention. The goal of this type of therapy is to lead the person to a "healthy remorse."

Social skills training. The impetus for social skills training is the belief that paraphilias develop in individuals who lack the ability to develop relationships. Social skills training focuses on such issues as developing intimacy, carrying on conversations with others, and assertiveness skills. Many social skills training groups also teach basic sexual education.

Twelve-step groups. These groups offer social support and emphasis on healthy spirituality found in these groups, as well as by the cognitive restructuring that is built into the twelve steps. Many individuals with paraphilias benefit from Twelve-step programs designed for sexual addicts. These programs are generally peer-facilitated. Examples of Twelve-step groups include Sexual Addicts Anonymous, Sex and Love Addicts Anynymous and Sexaholics Anynymous.

Couples therapy or family therapy. This approach is helpful for patients who are married and whose marriages and family ties have been strained by their disorder.

Medications. Medications that can be helpful in working with sexual deviations can include:

20. Antidepressants (such as Prozac) Fluoxetine (Prozac) and lithium help people with paraphilias control their impulses. 21. Gonadotropin-releasing hormones like triptorelin reduce the levels of testosterone and may lower sex drive.

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22. Phenothiazines, such as fluphenazine (Prolixin) can lower aggression and related fantasies. 23. Mood stabilizers such as divalproex sodium (Depakote) treat underlying conditions such as bipolar disorder (which can sometimes lead to hypersexuality). 24. Antiandrogens (drugs that are used to suppress or block the action of testosterone and DHT, dihydrotestosterone, the primary masculinizing hormones in the human body. Antiandrogens like medroxyprogesterone (Depo-Provera) lower sex drive.

Chapter 7 Topics in Human Sexuality: Sexual Compulsivity

Introduction

Case Vignette Consider the following case that involved a prominent politician:

Anthony Weiner, former seven-term congressman from New York, was implicated in multiple sex scandals both while in office and subsequent to his resignation. The initial scandal, known in the popular press as “Weinergate,” involved sending sexually explicit material by cell phone (“sexting”) by to a 21-year-old woman. After initial denials, he resigned from his congressional seat in 2011. In 2013 Weiner attempted to enter the New York mayoral race, a move thwarted when additional pictures surfaced and which were sent after his resignation from congress. In September 2016 Weiner was accused and eventually pled guilty to sexting with a 15-year-old. His wife filed for divorce on the day that charges against Weiner were filed.

Weiner’s case, and many like it, provide a basis for understanding sexually compulsive behaviors. Sexual compulsivity (also known as sexual addiction, hypersexuality, excessive sexuality, or problematic sexual behavior) is characterized by repetitive and intense preoccupations with sexual fantasies, urges, and behaviors that are distressing to the individual and/or result in psychosocial impairment (Derbyshire & Grant, 2015). These behaviors are often escalating, and can involve behaviors that range from solitary (such as uncontrollable masturbation or extensive use of pornography) to sexting, webcamming or obscene phone calls. Sexually compulsive behaviors may also involve illegal acts, such as exhibitionism.

While behaviors such as Weiner are often termed “sexual addiction” this label is somewhat controversial, both in the field of mental health/addiction and to the general public, and is not a clinical term per se but is often used in the field. Formal criteria for “Hypersexuality Disorder” was considered for inclusion in DSM-5, but was not adopted. While there may be a number of reasons for this, some people in the addiction field will only utilize the term “addiction” if a behavior involves ingestion of a psychoactive substance. This argument is somewhat weakened due to the inclusion of pathological gambling as a behavioral addiction rather than an impulse control disorder in prior DSM versions. Additionally there is the argument that a “sexual addiction” may be an excuse for infidelity. Others consider these behaviors to be more of a syndrome, with subtypes such as “compulsive sexual behavior,” “pornography addiction,” “compulsive masturbation,” etc. Above all, there has not

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96 yet been the type of empirical study devoted to sexually compulsive behaviors as there has been for other types of addiction, such as alcohol addiction. Hypersexual behaviors can also occur during the course of another major mental illness, such as a manic episode in bipolar disorder. It is interesting to note that physiological disorders of low sexual arousal (such as erectile dysfunction and female sexual arousal disorder) are included in the DSM-5.

Diagnostic categorization notwithstanding, it is likely that many mental health professionals will encounter individuals with sexually compulsive behavior patterns in their practices. Prevalence statistics vary, with Ewald (2003) estimating that about 6% to 8% of Americans have sexual patterns indicative of a sexual compulsivity; Kuzma & Black (2008) estimate prevalence at 3% to 6% in the US adult population. The later study states that compulsive sexual behavior typically begins in late adolescence or early adulthood, is thought to be chronic or episodic, and is more common among men than women. While this gender difference continues to exist, more study is needed. One recent study recent study found that 3.1% of women who responded to an online survey were characterized as hypersexual (as measured by control of sexual thoughts, urges and behaviors, and the use of sex as a coping strategy) (Reid R. C., Garos S. & Carpenter, B.N., 2011). A study of gay, lesbian, and bisexual individuals in a community sample reported a compulsive sexual behavior rate of 27.9%, but that study included both paraphilic and non-paraphilic sexual behavior in it’s definition, likely accounting for the high percentages. Among psychiatric inpatients, rates of compulsive sexual behaviors are between 1.7% and 4.4% (Müller et al., 2011). Estimating the prevalence of compulsive sexual behavior is difficult, due to the embarrassment and shame frequently reported by those with compulsive sexual behavior. The majority of treatment-seeking individuals with hypersexuality are males (Coleman, Raymond & McBean, 2003).

Substance use, mood, anxiety, and personality disorders are common comorbid conditions with hypersexual disorders, as are impulse control disorders such as Attention Deficit Hyperactivity Disorder (Coleman, Raymond & McBean, 2003), pathological gambling and compulsive buying (Grant Levine & Potenza, 2005.) Sexual compulsivity is also seen in individuals with autism, including Asperger’s (Deepmala & Agrawal, 2014). Hypersexual behavior can lead to medical complications including genital trauma or sexually transmitted diseases. Risk factors for Hypersexual Disorders include childhood sexual abuse (Kuzma & Black, 2008) and a family history of addiction (Carnes, 2001).

Sexual compulsivity and sexual anorexia, which Patrick Carnes (2015) describes as “sex in the extremes,” affects all facets of individuals’ lives. Reliance on sexual activities as maladaptive coping skills can be as destructive as addiction to chemical substances. People who engage in compulsive sexual behaviors may experience psychological distress, lose their livelihoods, and ruin meaningful relationships.

While literature on sexual compulsivity/addiction is more limited than that of other substance/process addictions, it does provide insight into treating this difficult issue. There are many facets to treatment, including helping clients to recognize the function of the behavior in order to decrease the tremendous shame around it. Carnes (2015) attributes the etiology of sexual compulsivity disorders to a combination of psychodynamic and

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97 cognitive-behavioral factors. He stresses abstinence, shame reduction, and rebuilding the capacity for healthy intimacy as primary tasks of the first three years of treatment. The following discussion will expand upon these concepts.

Educational Objectives

• Define sexual compulsivity. • Define sexual anorexia. • Describe prevalence and gender differences in sexual compulsivity. • Discuss the role of trauma in the development of sexual compulsivity. • List the components of healthy sexuality. • Discuss Internet sex and pornography addiction. • Describe treatment of sexual addiction.

Defining Sexual Compulsivity

The definition of sexual compulsivity previously discussed and endorsed by the National Council on Sexual Addiction and Compulsivity is that sexual compulsive behavior is characterized by “engaging in persistent and escalating patterns of sexual behavior acted out despite increasing negative consequences to self and others.” In other words, the person struggling with behaviors will continue to engage in these patterns despite facing potential health risks, financial problems, disrupted relationships or even arrest.

Sexually compulsive behaviors were first identified in the 1970s, but began to be a focus of study in the 1990s. Goodman (1998), in an early definition still employed by many experts, defined sexual addiction as a condition characterized by two key features: 1) recurrent failure to control the sexual behavior (i.e. failed attempts to quite or cut back), and 2) continuation of the sexual behavior despite significant harmful consequences (e.g., consequences to relationships, trouble at work or school, loss of interest in nonsexual activities, financial problems, loss of community standing, shame, depression, anxiety, legal issues.) Goodman points out that no form of sexual behavior in itself constitutes sexual addiction. The significant features that distinguish sexual addiction from other patterns of sexual behavior are: 1) the individual is not reliably able to control the sexual behavior, and 2) the sexual behavior has significant harmful consequences and continues despite these consequences. Experts in sexual addiction and compulsivity also include the element of sexual preoccupation to the point of obsession as another distinguishing trait (Weiss, 2016). Weiner’s case exemplifies these characteristics.

Sexual compulsivity involves many types of problematic sexual behaviors. The most commonly reported compulsive sexual behaviors are masturbation (17–75%) (Reid, Carpenter & Lloyd, 2009) compulsive pornography use, including use of Internet pornography (48.7– 54%) (Briken et al., 2007), promiscuity and multiple relationships (22–76%) (Reid, Carpenter & Lloyd, 2009). While these behaviors are often seen in the literature, there may be other representations that are not listed in the findings above.

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Additionally these behaviors may occur in conjunction with one another, such as a person that compulsively masturbates while viewing pornography.

Carnes (2015), a leading expert in the field, utilizes a similar definition. He further adds that people who engage in sexually compulsive behaviors hold a number of universal core beliefs: 20. "I am basically a bad, unworthy person." 21. "No one would love me as I am." 22. "My needs are never going to be met if I have to depend on others." 23. "Sex is my most important need."

Additionally, compulsive sexual behavior is often triggered by negative mood states including sadness and depression.

Sexually compulsive behavior has been viewed through the lens of Griffiths’ (2005) components’ model of addiction: (i) salience (sexual behavior dominates the individual’s thinking, feelings, and behavior), (ii) mood modification (mood elevates as a result of engaging in hypersexual behavior), (iii) tolerance (the need for increased levels or intensity of the sexual behavior to achieve the desired effect), (iv) withdrawal (the person experiences a sense of withdrawal – such as irritability and moodiness – when they discontinue the pattern of sexual behavior), (v) conflict (conflict due to spending excessive amounts of time engaged in sex-related behavior), and (vi) relapse (the tendency for repeated reversions to earlier patterns of sexual behavior to recur after prolonged periods of abstinence or control) (Van Gordon, Shonin, & Griffiths, 2016).

The case vignette below illustrates many of the core beliefs that Carnes describes, and also further illustrates the difficult nature of sexually compulsive behaviors. Research (Parsons, Grov, and Golub, 2012) has shown that individuals with sexually compulsive behaviors are also likely to engage in high risk behaviors including those that could result in HIV transmission (e.g., condomless anal sex and multiple sexual partners).

Case Vignette

John, a 28-year-old gay is presented for treatment with a psychologist specializing in sexual compulsivity. In exploring John’s goals, he stated that he knew that his self-esteem had always been low, that he felt “horrible” about his body, and while he wanted nothing more than a committed relationship he did not actually believe that he would find someone who really loved him. He spent evenings either webcamming online or "cruising" local parks, public restrooms, and pornographic bookstores for sexual contacts. This activity consumed numerous hours each day. His primary outlet was sex with multiple anonymous partners. When he learned of a recent increase in the number of local gay men that had tested positive for HIV, he began to worry constantly about his risk of contracting the virus. Still, he was unable to change his unsafe sexual practices despite repeated promises to himself to do so. While he is seeking change through therapy, he reported feeling overwhelmed and as if he could not possibly be helped.

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DSM-5/ICD 10 Diagnosis

In attempting to formally diagnose sexually compulsive behaviors, clinicians who treat these disorders frequently struggle with diagnostic categorization. Despite a successful field trial supporting the validity of the criteria for “Hypersexual Disorder” (Reid et al., 2012) the APA rejected the diagnosis for inclusion in the DSM-5. According to Piquet- Pessôa et al. (2014) cited concerns involved the lack of research including anatomical and functional imaging, molecular genetics, pathophysiology, epidemiology, and neuropsychological testing. There were also concerns that a diagnosis of Hypersexual Disorder could lead to forensic issues or produce false positive diagnoses, given the absence of clear distinctions between normal and pathological levels of sexual desires and behaviors (Moser, 2013).

Similar to the DSM-5, the ICD-10-CM (2017) does not include “Excessive Sexual Drive” as a diagnosis. The recommendation was to use the diagnostic code F52.8 (Other Sexual Dysfunction Not Due to Substance or Known Physiological Condition.) Weiss (2016) comments that this diagnosis continues to utilize terminology that is both dated and potentially offensive to people with sexual compulsivity, such as the descriptors “nymphomania,” and “satyriasis.”

The DSM-5 contains similar diagnostic entities: Other Specified Sexual Dysfunction and Unspecified Sexual Dysfunction.

Other Specified Sexual Dysfunction (302.79), is defined as follows, which indicates a sexual disorder that causes clinically significant distress but does not meet full criteria for another sexual dysfunction and which allows for the person making the diagnosis to include a specific reason such as “sexual compulsivity.” Another option is the selection Unspecified Sexual Dysfunction (302.70), which is essentially the same diagnosis but does not require the clinician to include a specifier (typically used in contexts in which there is insufficient information).

The diagnosis “Compulsive Sexual Behavior Disorder” is being studied inclusion in ICD-11 (scheduled for publication in 2018). Weiss (2016) cites the following definition posted on the ICD-11 beta draft website.

Compulsive sexual behavior disorder is characterized by persistent and repetitive sexual impulses or urges that are experienced as irresistible or uncontrollable, leading to repetitive sexual behaviors, along with additional indicators such as sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other activities, unsuccessful efforts to control or reduce sexual behaviors, or continuing to engage in repetitive sexual behaviors despite adverse consequences (e.g., relationship disruption, occupational consequences, negative impact on health). … The pattern of sexual impulses and behavior causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

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For the present time, there are limitations to formal diagnostic coding.

Prevalence and Gender Differences

Case Vignette

Naomi, a 27-year-old woman is seeking treatment due to severe depression. During her assessment, she shared with her therapist that she does not seem to have trouble finding relationships, but does have difficulty sustaining them. Naomi has had “relationships” with 10 men this month alone, all of them sexual and none of them lasting more than two weeks. She seems confused when her clinician suggests that she may have difficulties with sexual compulsivity.

Due to the secrecy and shame associated with sexual compulsivity, it is difficult to get a reliable estimate of the rate of hypersexual behavior and prevalence statistics are likely underestimated. The National Association of Sexual Addiction Problems estimates that 6 to 8 percent of Americans are sexually compulsive (Ewald, 2003). About 8% of men and 3% of women from the population in the US are sexually compulsive. This constitutes over 15 million people. The literature suggests that like other addictions sexual compulsivity is nonselective and spans all ages, religions, and social stratas, and that both genders and all sexual orientations are represented. It is important to assess clients presenting with sexually compulsive behaviors within the context of age and other life factors. For example, college students living away from home for the first time may be more likely to engage in “excessive sexual exploration” due to being away for the first time (Cohen, 2008).

In working with male and female sex addicts, one anecdotal difference often cited by clinicians is male addicts’ objectification of sexual partners (e.g., exploitive sex, paid sex), and their use of sex as a way to feel powerful (Carnes, Nonemaker, and Skilling, 1991). In contrast, some women appear to seek “relationships” through their sexual activities. A National Council on Sex Addiction and Compulsivity position paper (2000) on female sex addicts suggests that most sexually compulsive women have not had appropriate role models to teach them how to achieve emotional intimacy in nonsexual ways.

Causal Theories/Etiology Of Sexually Compulsive Behavior

Case Vignette

James, a 40-year-old man struggling with Internet-based sexual compulsions has been in treatment working on the behaviors. In looking at the types of sites and pornography he is seeking, his therapist comments that there seems to be a pattern of him selecting older women with fair complexions. In asking whether that reminds him of anyone, James breaks down and talks about his relationship with his mother, who was overly sexual, such as wearing only

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101 underwear around the house when James was a young boy. He often wonders if that had affected him in any way.

Psychological

While it is difficult to generalize, research has shown that sexual compulsivity is often rooted in adolescence or childhood, especially in experiences of abuse. Sixty percent of sexual addicts were abused by someone in their childhood (Book, 1997). Children who become sexually addicted may have grown up in harsh, chaotic or neglectful homes, or they may have been emotionally starved for love and affection. Boundaries in the family may have been overly rigid or permissive, which inhibited personal growth and individuality. For children growing up in these environments, sex may become a replacement for any kind of need, from escaping boredom, to feeling anxious, to being able to sleep at night. Sexual compulsivity may begin as the child turns to masturbation for diversion (Ewald, 2003). In other cases, the child maybe introduced to sex in inappropriate ways, such as through sexual abuse by a trusted adult or by an older child (Carnes, 2001).

Oftentimes, early trauma results in confusion about sexuality and sexual expression. People with hypersexuality are acting on a compulsion to act out sexually. Those struggling with sexual compulsivity often do not understand why they are acting out.

Trauma also affects one’s ability to be intimate sexually and the act of sex become confusing. Sexual compulsivity instead recreates the original act of abuse by misusing power or exploitation (Ewald, 2003). There is also little comprehension among many abuse survivors that certain behaviors are risky or degrading. There is often a secretive aspect to sexual compulsivity.

24. Emotional Dysregulation and Impulsivity

Case Vignette

Larry is a 23-year-old male college student. Somewhat of a late bloomer with a history of ADHD, Larry initially presented for treatment of a binge eating disorder. During the course of the treatment, Larry disclosed what he terms a “sexual addiction.” He describes spending more and more time surfing the web for hook up opportunities such as on Tinder. Many of these encounters are with older women. When asked to describe some of the functions of these “hookups,” he stated that while he used to feel a sense of relief after binging, that is no longer the case. After the encounters with anonymous partners he describes feeling “calm” and “more relaxed.” Larry has tried multiple times to stop this behavior but has not met with success.

Emotional dysregulation is a state in which affective responses are poorly modulated. Emotional dysregulation can be associated with early psychological trauma, brain injury, or chronic trauma, attachment disorders, attention deficit hyperactivity disorder, bipolar disorder, borderline personality disorder, and complex post-traumatic stress disorder. Emotional dysregulation is also found among those with autism spectrum disorders. It is

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102 interesting that the aforementioned conditions are associated with hypersexual disorder, and may be an important mechanism in the etiology and treatment of sexual compulsivity.

Carnes (2009) theorizes that sexual compulsivity may be used as a means of self-soothing. “Contrary to enjoying sex as a self affirming source of physical pleasure, the addict has learned to rely on sex for comfort from pain for nurturing or relief from stress” (Carnes, 2009b, pp 34). The need for excitement distracts from the individual’s internal pain.

Emotional dysregulation and its connection to hypersexuality has also been a subject of research. Dhuffar, Pontes & Griffiths (2015) studied the role of emotional dysregulation and negative mood states as predictors of sexual compulsivity in a group of 165 British university students. They found that negative mood states and affective dysregulation significantly predicted hypersexual behaviors. Previous studies (e.g., Bradley, 2000) have also suggested that the use of sex allows for the distraction or the contraction of negative emotions.

Role of

There is also emerging evidence that looks at the role of neurotransmitters in sexually compulsive behavior. The primary neurotransmitters that have been a focus of study have been the monoamines, namely serotonin, dopamine, and norepinephrine (Kafka, 2003). Cases of hypersexual behavior have also been shown to be induced by medications for Parkinson's disease, implicating dopamine systems in compulsive sexual behaviors (Riley, 2002).

Pornography and Internet Sexual Compulsivity

The term pornography refers to written material or pictorial content of a sexually explicit nature that is intended to elicit sexual arousal in the reader or viewer (Kraus, Martino & Potenza, 2016). According to surveys, 30%–70% of heterosexual and gay/bisexual men report recreational use pornography. In women this statistic is significantly lower (<10%) (Wright, 2013). Researchers agree that not all use of pornography is either negative or compulsive.

Researchers Hald and Malamuth (2008) studied the self-perceived effects of pornography consumption in a large sample of young adult Danish men and women aged 18-30. They assessed participants' reports of how pornography has affected them personally in areas including their sexual knowledge, attitudes toward sex, attitudes toward and perception of the opposite sex, sex life, and general quality of life. Participants reported only small, if any, negative effects with men reporting slightly more negative effects than women. Moderately positive effects were generally reported by both men and women, with men reporting significantly more positive effects than women. The researchers concluded that pornography may be a healthy sexual outlet for many people. There are, however, some individuals for whom pornography use becomes both excessive and problematic. This is particularly true for Internet-based pornography, sex chat rooms and webcamming.

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Rosenberg (2010) lists the following signs of Internet Sexual Addiction

• Spending progressive amounts of time on the Internet • Behavior begins to affect other areas of the individuals life, such as work, family, hobbies • Binge-style of sexual or Internet behavior • Unsuccessful efforts to cut down, or stop altogether • Experiencing guilt and shame following the sexual behavior • Others indicate that the person spends too much time on the Internet • Experiencing money or legal problems because of Internet use • Thoughts of "getting online", or of sexual behavior, are compulsive even when not online or engaged in sexual behavior (i.e. work, with family, etc.) • Lies or excuses for behavior • Using sexually explicit material to cope with anxiety or dysphoric mood

Problematic use of pornography is frequently reported by those seeking treatment for compulsive sexual behavior (Kraus, Potenza et al., 2015), although this behavior also has to be assessed within the context of the individual’s age and life situation. Consider the following case:

Case Vignette

Marcus is a 16-year-old teen who has been experiencing feelings of attraction to some of the boys he is in baseball with. He feels confused and overwhelmed. He has been frequently perusing online gay pornography, and this has become a source of conflict in his household between his parents. Lately the behavior has been occurring multiple times per day and often impede on his ability to accomplish other tasks such as school work.

In this case it would be important to consider Marcus’ entire life context. Is this a way of exploring his sexuality or is it indicative of a compulsive behavior? In contrast, consider the following case:

Gerald is a 30-year-old man recently mandated to treatment for sexually compulsive behavior. He reports spending up to 6 hours a day viewing both print-based and online pornography. While he recognizes that the behaviors are problematic, and has tried to stop them, he has not been successful. Gerald lives alone, and his housing is paid for by his parents. The impetus for treatment was that Gerald had visited Internet sites that he did not realize contained sexually explicit content related to minors. He has opted for a chance at rehabilitation rather than punishment, and appears motivated to working on what is underlying the compulsive pornography use.

Given Gerald’s example and others contained in this material it is helpful to understand what motivates some people to seek treatment for problematic use of pornography. Gola, Lewczuk, and Skorko (2016) found that negative symptoms (e.g., preoccupation, affect, and

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104 relationship disturbances because of sexual behaviors and impaired control) were significantly associated treatment-seeking.

Kraus, Martino and Potenza (2015) studied treatment-seeking behaviors among 1,298 men who frequently used pornography in order to identify factors (e.g., demographics and sexual history characteristics) associated with these individuals’ self-reported interest in seeking treatment. Out of the 1,298 individuals surveyed, 14.3% reported a interest in seeking treatment for use of pornography. Treatment-interested men were more likely to be single and to have made more “cut back” attempts with pornography, and more quit attempts with pornography. They were also more likely to have previously sought treatment for use of pornography. Findings suggested that interest in treatment may be explained, in part, by pornography users’ sense of “loss of control” over their sexual thoughts and behaviors related to pornography.

Dimensions of Healthy Sexuality

Due to the difficulties that those with sexual compulsivity have in understanding healthy sexuality, it is important to help them create a schema for what healthy sexual expression entails. Carnes (1997) presents the following dimensions of healthy sexuality:

• Nurturing ¾ capacity to receive care from others and provide care for self. • Sensuality ¾ mindfulness of physical senses that create emotional, intellectual, spiritual, and physical presence. • Self image ¾ positive self-perception that includes embracing the sexual self. • Self-definition ¾ clear knowledge of oneself (both positive and negative) and the ability to express boundaries and needs • Comfort ¾ capacity to be at ease about sexual matters • Knowledge ¾ knowledge base about sex and one’s unique sexual patterns. • Relationship ¾ capacity to have intimacy and friendship with both those of the same gender and opposite gender. • Partnership ¾ ability to maintain an interdependent, equal relationship that is intimate and erotic. • Nongenital sex ¾ ability to express erotic desire without the use of the genitals. • Genital sex ¾ ability to freely express erotic desire with the use of the genitals. • Spirituality ¾ ability to connect sexual desire and expression to the value and meaning of one’s life. • Passion ¾ capacity to express deeply held feelings of desire and meaning about one’s sexual self, relationships, and intimacy experiences.

Differential Diagnosis

As mentioned earlier in this training material it is important to rule out medical causes of the hypersexuality. Compulsive sexual behaviors may be related to neurological disorders. For people affected by Alzheimer’s Disease and other illnesses of the frontal lobe,

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105 approximately 4-9% of patients experience sexual disinhibition (Cooper et al., 2009). Other diseases such as Pick’s Disease may impair the regulation of socially acceptable behaviors. Increased or extreme involvement in any sexual activity may also be a result of a psychiatric illness such as bipolar disorder or may be related to adverse effects of treatments (e.g. levodopa-treatment), substance-induced disorders (e.g. amphetamine substance use) (Sid et al., 2017).

Treatment of Sexual Compulsivity

Treatment of sexual compulsivity focuses on controlling the compulsive behavior and helping the person develop a healthy sexuality and healthy interpersonal relationships. Treatment generally includes:

• Education about healthy sexuality, including the dimensions discussed above, and about possible health and other consequences associated with sexual compulsivity (Hart et al., 2016). Psychoeducational groups also often discuss the addictive/compulsive nature of these behaviors, the role of triggers, and alternate coping skills.

• Defining recovery. The person seeking to recover from sexual compulsivity must learn to develop his or her own definition of recovery. This may mean not masturbating, not engaging in sexual relationships outside a committed relationship, or not accessing Internet sites.

• Individual counseling, to better understand the reasons behind sexual compulsion, triggers to compulsive behaviors, support abstinence from compulsive behaviors, and reinforce coping skills. Individual counseling also involves helping with shame reduction and rebuilding the capacity for healthy intimacy

o Cognitive Behavioral Treatment - focus on helping the person to identify core triggers and beliefs about sexual compulsions and to develop healthier choices and coping skills to minimize urges and deal with the preoccupation of sexual compulsions. Cognitive Behavioral Therapy also aims to help the individual to reshape cognitive distortions about sexual behaviors (e.g., “I'm not really cheating on my wife if I look at online pornography/frequent chat rooms”). Cognitive Behavioral Therapy also emphasizes relapse prevention. (Fong, 2006; Hart et al., 2016; Shraga & O’Donahue, 2003).

o Mindfulness Awareness Training – One intervention that can be utilized to support a decrease in cravings associated with sexual compulsivity is Mindfulness Awareness Training. The authors of a case discussion of the application of this approach (Van Gordon, Shonin, & Griffiths, 2016) propose that “contemplative observance of cravings and negative affective states helps

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to objectify these psychological phenomena, such that they become less consuming and can be let go of.” Van Gordon, Shonin, & Griffiths’ (2016) case, as well as mindfulness applications to a range of addictive/compulsive behaviors make this another area to explore with regard to treatment.

o Psychodynamic Therapy - Psychodynamic Therapy for compulsive sexual behavior explores the core conflicts that drive dysfunctional sexual expression. Some of the common themes explored by the therapist and client include shame, avoidance, anger, and impaired self-esteem and efficacy (Fong, 2006).

• Marital and/or family therapy, to resolve issues caused by the sexual compulsion and to develop and strengthen family boundaries.

• Support groups and 12 step recovery programs for people with sexual compulsions (like Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous) are very helpful, especially in reducing shame around the behaviors.

• Medications used to treat obsessive compulsive disorder may be used to treat the compulsive nature of the disorder. These include selective serotonin reuptake inhibitors (Prozac, Paxil) or medications specifically indicated for OCD such as Anafranil.

Sexual Anorexia or Sexual Interest/Arousal/Desire Disorder

Sexual compulsivity is one end of the addictive spectrum; at the other end of sexual anorexia. The DSM identifies a sexual disorder known as Hypoactive Sexual Desire Disorder. The features are a deficiency or absence of sexual fantasies and desire for sexual activity. This is considered a disorder if it causes distress for the patient or problems in the patient's relationships. If the sexual partner of a patient with suspected hypoactive sexual desire disorder feels that this is a problem within the relationship, that concern should be sufficient for the individual to seek support.

Carnes (2009) first coined the term sexual anorexia, which is similar to the DSM disorder but broader in scope. He uses the term to describe a loss of "appetite" for romantic-sexual interaction (Carnes, 1998). Sexual anorexia is an obsessive state in which the physical, mental, and emotional task of avoiding sex dominates one’s life. Like self-starvation with food, sexual deprivation can make one feel powerful and defended against all hurts.

Like other compulsive behaviors the preoccupation with avoiding sex can become a way to cope with life’s difficulties. For the sexual anorectic, the aversion to things sexual is a way to manage anxiety and avoid more painful life issues. Food anorexia and sexual anorexia share

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107 a number of similarities including the essential loss of self, distortion of thought, and struggle for control over self and others.

The sexual anorexic typically experiences the following:

• A dread of sexual pleasure • A morbid obsession and persistent fear of sexual contact • Obsession and hypervigilance around sexual matters • Avoidance of anything connected with sex • Preoccupation with being sexual • Distortions of body appearance • Extreme shame and loathing about sexual experiences, their bodies, and sexual attributes. • Obsessive self-doubt about sexual adequacy • Rigid, judgmental attitudes about sexual behavior

As with the sexual compulsive, the sexual anorexic’s aversion affects their work, hobbies, friends and families. They obsess about sex so much it interferes with normal living. They may also have periods of sexual bingeing or periods of sexual compulsivity.

Female Sexual Interest/Arousal Disorder

In the DSM IV, such disorders were termed “Hypoactive Sexual Disorders”; DSM-5 introduces a new term “Sexual Interest/Arousal Disorder” and divides the category into gender-specific disorders. The primary criteria of Female Sexual Interest/Arousal Disorders include:

1. Absent/reduced interest in sexual activity 2. Absent/reduced sexual/erotic thoughts or fantasies 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75%-100%) sexual encounters. 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual) 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational contexts or, if generalized, all contexts).

These symptoms must cause clinically significant distress.

The DSM-5 clarifies that a “desire discrepancy,” in which a women has a lower sexual desire for sexual activity than her partner is not sufficient to make this diagnosis. Female Sexual Interest/Arousal Disorder is frequently associated with problems experiencing orgasm and/or pain experienced during sexual activity. Substance/medication use may also be

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108 factors to look at (such as antidepressant medications) as are inadequate or absent sexual stimuli. The DSM-5 also considers that other factors may explain difficulties with sexual arousal/excitement. These factors include physical problems (e.g., hormonal imbalances, alcohol or substance abuse, depression, certain medications that can reduce libido including antidepressant medications) and psychological causes (e.g., stress and anxiety, work pressures/home-life balance, guilt, relationship problems, past sexual trauma).

While the DSM-5 does not cite prevalence statistics for Female Sexual Interest/Desire Disorder, Kingsberg and Rezaee (2013) conducted a literature review of the epidemiology, diagnosis, and treatment of low sexual desire/hypoactive sexual desire disorder. These rearchers found that low sexual desire is high, reaching 43%, although patterns meeting criteria for clinically significant distress comes close to 10%. The authors conclude that subclinical problems with sexual desire are the most prevalent sexual problem in women, making it important to determine more about treatment options.

Case Vignette

Anne, a 32-year-old married, mother of two, entered treatment due to what appeared to be a generalized anxiety disorder. Within the course of therapy she revealed that this anxiety was actually due to constant fears of her husband’s (and other men’s) potential sexual advances. She reports anxiety in thinking about the weekend approaching, as this is the time that her husband may be most likely to initiate sexual activity. She states that she has “never” had an orgasm or initiated sexual contact with her husband. In exploring the precipitants of this condition, Anne describes a childhood history of growing up in an extremely religious conservative family in which signs of sexuality in women were severely punished.

Case Vignette

Dorthea, a morbidly obese 60-year-old woman is being treated for binge eating disorder. While she appears similar to many with this concern, her history and success in resolving the eating issue is complicated by the function that binge eating serves: her large body is a shield against potential sexual interest from others. Dorthea describes extreme fears of intimacy, especially sexual intimacy, although concurrently has obsessive thoughts of appearing overly sexual with many of the men she works with. She is unpopular with female coworkers due to often “policing” their dress and behaviors as “flirtatious” and “inappropriate.” When faced with the potential of genuine interest in dating from a male coworker, Dorthea becomes overwhelmed, and is uncertain how to proceed as she likes him as a person but cannot fathom why he would be interested.

Male Hypoactive Sexual Disorder

DSM-5 also contains a diagnosis reserved for men, which is called Male Hypoactive Sexual Disorder. As with Female Sexual Interest/Arousal Disorder, this disorder describes an abnormally low level of desire for sexual activities in a man. To meet for this diagnosis, the male must show, “persistently or recurrently deficient (or absent) sexual/erotic thoughts

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109 or fantasies and desire for sexual activity” to a degree that causes impairments in the man’s life or relationships. The diagnosing clinician should take into account various factors that could affect sexual functioning, such as age (e.g., sexual dysfunction associated with diseases of aging) and the context of the person’s life (partnered versus single, marital or relationship dysfunction, medical causes such as the presence of diabetes, kidney disease or other chronic issues, etc). For some men, there may also be performance anxieties that result in restriction of sexual interest.

Case Vignette

Carolyn is a 45-year-old married woman presenting for therapy due to relationship issues and low self-esteem. She reports that the difficulties are relatively recent, and are connected to her husband Bruce’s seeming sexual indifference. While they used to have an active sex life, recently this has stopped, and he redirects her advances or attempts to initiate. While she says that she loves Bruce, she is hurt by his lack of interest in her and his disinterest in going to a doctor, wonders if she is unattractive. She states that if things do not improve she may consider ending the marriage.

Summary

This training material has looked at the etiology and treatment of sexual compulsive and restrictive behaviors. While study of these complex behaviors continue, some important points are listed below:

• Healthy sexuality involves nurturing, sensual and consensual behavior

• Sexually compulsive behaviors should be assessed within the framework of age, life circumstances and presence of other diagnoses (physical and psychological).

• They are diagnosed only when they cause significant distress or impairment

• There is no one etiological factor to sexual compulsivity or sexual anorexia, but trauma may play a role

• Treatment may involve counseling, psychoeducation, group support, medication of a combination of the above

Chapter 8 Topics in Human Sexuality: Sexual Orientation

Introduction

Case Vignette Neil is a 45-year-old man presenting for therapy. In the initial assessment Neil was open about his sexual orientation. He was quick to note this openness was hard won, and describes

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110 that in his teens, 20s and early 30s, he underwent a constant internal battle to deny his feelings for other men. He dated several women during those years, but “always knew” that he was not really attracted to them, but this did not stop his efforts to find an “acceptable” relationship. He describes attempting to subvert these feelings through involvement with a conservative church and through significant alcohol abuse. It was during one of his experiences in a treatment and through the efforts of a sensitive and accepting clergyman that he was finally able to embrace his sexuality. He has been able to establish connections with the local gay community, has dated several men, and has not had a drink since.

When many people think of sexual orientation, they often think of a simple definition: the gender to whom one is attracted. As Neil’s story illustrates, this is just part of the picture. The American Psychological Association (2008) defines sexual orientation as “an enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both sexes.” In addition, sexual orientation also refers to a person's sense of identity based on those attractions including related behaviors, and membership in a community of others who share those attractions. The key word here is identity; there is often a misperception that homosexuality only applies to a person’s sexual attractions.

Research over has demonstrated that sexual orientation ranges along a continuum from exclusive attraction to the other sex to exclusive attraction to the same sex (APA, 2008). Sexual orientation, however, is usually discussed in terms of four categories: tendency to be attracted to people of the same sex (homosexual orientation), of the opposite sex (heterosexual orientation), or of both sexes (bisexual orientation) and lack of sexual interest and attraction (asexuality). This is not unique to the United States and many cultures describe sexual attraction in this way, and attempt to label these behaviors.

In the United States the most frequent labels for these orientations are lesbians (women attracted to women), gay men (men attracted to men), and bisexual people (men or women attracted to both sexes). However, some people may use different labels or none at all. Another term that is sometimes used is queer. This was originally a derogatory label used to insult lesbians and gay men, but has more recently been reclaimed by some lesbians, gay men, bisexual people, and transgender people as an inclusive and positive way to identify all people targeted by homophobia.

Homophobia, or hatred of people with same-sex attraction, is damaging, as is biphobia. Biphobia is the fear of, discrimination against, or hatred of bisexuals, which is often times related to the current binary standard. Biphobia can be seen within the lesbian, gay and bisexual community, as well as in society at large.

In 1997 The American Psychological Association issued a position statement on “conversion treatment,” approaches that involve trying to “force” someone to become heterosexual. The position statement says “. . . societal ignorance and prejudice about same-gender sexual orientation put some gay, lesbian, bisexual and questioning individuals at risk for presenting for "conversion" treatment due to family or social coercion and/or lack of information (Haldeman, 1994). Since that time, educational efforts on behalf of the

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APA and other professional organizations have targeted educating others about homosexuality and decreasing prejudice and misunderstanding.

As of April 2011, approximately 3.5% of American adults identify as lesbian, gay or bisexual, while 0.3% identify as transgender—approximately 11.7 million Americans (Gates, 2011). More recent surveys are yielding higher numbers, such as a 2012 Pew survey that puts these figures closer to 5% (Pew Research, 2013).

This chapter will look at the development of sexual orientation and provide a basis for caring therapeutic intervention.

Educational Objectives

1. Define the term “sexual orientation” 2. Discuss the development of sexual orientation. 3. Discuss instances and effects of prejudice and discrimination, including internalized homophobia. 4. Discuss the historical factors in the view that homosexuality is a mental disorder, and describe current beliefs. 5. List stages in the coming out process. 6. Describe tips for working with gay and lesbian clients.

Defining Sexual Orientation

As defined by the APA, sexual orientation is an enduring pattern of emotional, romantic, and/or sexual attraction. It also includes a person’s self-identification and sense of who they are based on those attractions, as well as their community of supports. It is important to note that sexual orientation is distinct from other components of sex and gender, such as biological sex, gender identity (the psychological sense of being male or female), and social gender role (norms that define feminine and masculine behavior). People who are transgender can be heterosexual, homosexual or bisexual.

What is most important in the definition above is that sexual orientation is not simply a trait, but should be defined in terms of relationships with others.

There is some debate as to how early people are aware of their sexual orientation. Herdt and McClintock (2000) believe that sexual orientation is formed by middle childhood. They state: "Accumulating studies from the United States over the past decade suggest that the development of sexual attraction may commence in middle childhood and achieve individual subjective recognition sometime around the age of 10. As these studies have shown, first same-sex attraction for males and females typically occurs at the mean age of 9.6 for boys and between the ages of 10 and 10.5 for girls." Thus comments to gay/lesbian youth indicating such as “this will change when you get older” can be inaccurate and harmful. What is important to note here is that while adolescence can be a period of experimentation, and many youths question their sexual feelings, allowing them to explore

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112 these feelings in a nonjudgmental way is key. Many lesbian, gay or bisexual youths engage in patterns of sexual behavior that are enduring.

Similarly the American Psychological Association (2008) states that the core attractions that form the basis for adult sexual orientation typically emerge between middle childhood and early adolescence.

It is likely that sexual orientation emerges prior to any sexual experience. People can be celibate and still know their sexual orientation. Having had sex with someone of the same gender does not always mean that a person is gay, and many gay/lesbian or bisexual people have never had sex with someone of the same gender. There has also been discussion as to whether sexual/romantic orientation is stable or can change over the course of a person’s lifetime. Additionally, some suggest that sexual and affectational preferences are not always congruent (Canadian Pediatric Society, 2008.)

Development of Sexual Orientation

What influences a person to be gay, lesbian, straight or bisexual? Is sexual orientation a function of nature, nurture, or a combination of the two? Although numerous studies have attempted to answer this question, there is little consensus among researchers as to the definitive answer. Thus research has examined the possible genetic, hormonal, developmental, social, and cultural influences on sexual orientation. No research has determined one specific factor.

Our current thinking is that both nature and nurture play complex roles and that most people experience little or no sense of choice about their sexual orientation (APA, 2008). This view is helpful in remediating the prejudice that gay men and lesbian women often encounter.

Prejudice, Discrimination, Scope and Impact

Case Vignette Karina, an openly lesbian woman tells a shocking story about what she has experienced as a result of prejudice and misunderstanding. Karina’s physical appearance is what may be considered more masculine. She describes going to a bar in her mid-twenties, and being regaled with comments from visibly intoxicated males about her appearance. When she left the bar, two men followed her and she was raped, while being told by these men that they could “change her.”

This is a true experience that not surprisingly did not “change” Karina’s sexual orientation, but did leave scars that took years to heal. Lesbian, gay, and bisexual people in the United States encounter extensive prejudice, discrimination, and violence because of their sexual orientation. Opinion studies over the 1970s, 1980s, and 1990s routinely showed that

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113 homosexuality was viewed negatively by the American public. Although there may be a shift in this thinking, expressions of hostility, such as the one described in the case vignette, still remain common in contemporary American society. People who are lesbian, gay, bisexual or transgender face a number of challenges that their straight counterparts may not. These include increased risk for victimization and violence, mental health problems and substance abuse, a variety of health risk behaviors, and suicide (Bontempo & D'Augelli, 2002; King et al., 2008).

These disparities extend very deeply even into the medical and mental health systems. Healthy People 2020 states that gay, lesbian, bisexual, and transgender health "requires specific attention from health care and public health professionals to address a number of disparities," including mental health and suicidal behavior (U.S. Department of Health and Human Services, 2012). People who identify as transgender are most at risk for discrimination and stigma.

Challenges may be particularly prevalent among LGBT youth; In addition to the usual issues faced by all adolescents, LGBTand questioning (GLBTQ) adolescents must also face the persistent social stigma associated with sexual minorities in America. Youths who identify as lesbian, gay, or bisexual may be more likely to face problems, including being bullied and having negative experiences in school. These experiences are frequently associated with negative outcomes, such as suicidal thoughts, and high-risk activities, such as unprotected sex and alcohol and drug use. This is not a universal: many lesbian, gay, and bisexual youths appear to experience no greater level of health or mental health risks.

There are a number of “myths” about homosexuality and which may influence some of these negative societal attitudes. As the sampling below illustrates, these myths are extremely destructive:

Myth: Homosexuality is a result of family dysfunction, such as an overprotective mother. Myth: Homosexual parents are more likely to molest their same-gender children. Myth: Homosexuality is a moral failing. Myth: People choose to be homosexual as a way of rebelling. Myth: Male homosexuals cannot form committed relationships and only engage in casual sex. Myth: Homosexuals do not make good parents. Myth: Lesbians are always “butch.” Myth: Only homosexual therapists can be effective with gay clients.

It is important to remember that these beliefs continue to exist. Although many people know that these are untrue, gay men and lesbian women encounter these frequently.

Perhaps less overtly destructive, but certainly detrimental, is discrimination against lesbian, gay, and bisexual people in employment, housing and parenting issues. There are also pervasive stereotypes about gay men and lesbian women. Bisexual men and women

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114 often face the view that they just need to make up their minds about their sexual orientations. As a whole, such discrimination sends the message to gay men and lesbian women that they are “less than,” and this has lasting effects.

The following belief systems about homosexuality may be seen. There is distinct continuum in these beliefs (Tolerance, 2011). Mental health professionals need to be aware of their own beliefs and prejudices about gay, lesbian and bisexual behavior.

• Abomination: Homosexual behavior is profoundly immoral at all times; there are no exceptions.

• Change is expected: Gay men and lesbian women can and must make every effort to change their sexual orientation to become heterosexual.

• Celibacy: If a homosexual cannot change their orientation, they must remain celibate.

• Marginally acceptable: Loving committed same-sex relationships are somewhat acceptable, and much better than singles living promiscuously.

• Affirmation: Homosexuality is morally neutral. Persons of all sexual orientations deserve equal rights.

• Liberation: Full acceptance and valuing of persons of all sexual orientations.

Case Vignette Maria and her girlfriend Terry had been in a committed relationship for ten. When they decided they wanted to start a family, Terry, the income earner in the family, adopted two children from Viet Nam. The two partners parented the children, but Maria was the primary caretaker, staying at home with them. When the partners split up acrimoniously, Maria found that she no longer had rights to see her children. A visit to a lawyer confirmed that she could challenge Terry’s decision to keep the children from her, but her lawyer was pessimistic that the courts would rule on her behalf. Fortunately Maria’s lawyer proved to be a fierce advocate of Maria’s rights as a parent, and an out-of-court arrangement was drafted.

Stories such as that of Maria can be found in the personal narrative of most gay men or lesbian women. Such discrimination has social and personal impact. As with Max’s story, gay, lesbian and bisexual people may attempt to conceal or deny their sexual orientation, or may carefully choose whom they share their sexual orientation with. Although many lesbians and gay men learn to cope with the social stigma against homosexuality, this pattern of prejudice can have serious negative effects on health and well being, as well as their overall emotional health.

While coping with external prejudice is challenging, even more concerning is the internalization of societal messages. Theorists term this phenomena internalized

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115 homophobia. Internalized homophobia is defined as “the gay person’s direction of negative social attitudes toward the self, leading to a devaluation of the self and resultant internal conflicts and poor self-regard” (Meyer & Dean, 1998, p. 161). Studies have consistently demonstrated a relationship between internalized homophobia and depressive anxiety symptoms, substance use disorders, and suicidal ideation (Igartua, Gill, & Montoro, 2003; Szymanski, Chung, & Balsam, 2001) various forms of self-harm, including eating disorders (Williamson, 2000), as well as self-blame and poor coping in the face of HIV infection/AIDS. Research has also looked at how the combination of depression, low self-esteem, and internalized homophobia can result in relationship problems (Longares, Escartín, & Rodríguez-Carballeira, 2016).

Although an exhaustive look at these issues is not possible here, it is important for mental health professionals to talk with gay and lesbian clients about their experiences and self- concept. Social support is critical in helping men and women deal with these stressors. In fact, the explanation of minority stress ¾ stress caused from a sexual stigma, manifested as prejudice and discrimination ¾ is often used to explain some of the mental health issues faced by gay and lesbian clients. This is a dramatic shift from previous ideas that homosexuality itself was a mental disorder, and which is discussed in the following section.

Homosexuality as a Mental Disorder: An Important Shift

Case Vignette Barry, a 62-year-old gay male has recently consulted with Dr. Cherney. When questioned about the obvious trepidation he has in seeking counseling, Barry tearfully explains that as a young man he had worked with a therapist in order to try to change his sexual orientation. Although he is quick to point out that his experiences were similar to other men in his cohort, they left him feeling very shameful about his inability to repress his sexual attractions. Dr. Cherney validates that these experiences were very damaging, and that homosexuality is considered a normal and healthy sexual expression.

In writing about the shift in perspective on DSM diagnosis of homosexual sexual orientation (which we will discuss in the next section of this material), Drescher (2015) describes the typology of etiological theories of homosexuality throughout modern history as falling into three broad categories: pathology, immaturity, and normal variation.

Theories of Pathology

These theories regard adult homosexuality as a condition deviating from “normal,” heterosexual development, and something that should be a focus of mental health treatment. In pathology-based theories, there is thought to be an internal defect or external pathogenic agent causes homosexuality. For example, psychiatrist and psychoanalyst Edmund Bergler (1957), in his book, Homosexual: Disease or Way of Life? wrote: “I have no bias against homosexuals; for me they are sick people requiring medical help.” Bergler was also dismissive of bisexuality, seeing people of bisexual identity as homosexuals who could

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116 at time “engage in mechanical heterosexual activity; such activity provides him with the inner alibi he needs.”

Bergler believed that the influences from childhood experiences could affect a person’s view of the opposite sex and his own gender identity. It was only in dealing with these childhood influences, and their “inner guilt” that homosexuals could become hetrosexual. While beliefs such as these still underlie more controversial forms of treatment (such as conversion therapy, a form of counseling designed to change a person's sexual orientation from homosexual or bisexual to heterosexual) professional organizations such as the APA have spoken out against efforts to “mischaracterize homosexuality” and have also come down critically on forms of treatment that “promote the notion that sexual orientation can be changed and about the resurgence of sexual orientation change efforts” (Anton, 2010).

Immaturity: Freud and Psychoanalysis

Mental health, as a field, has undergone a shift in our understanding of homosexual behavior. A brief historical discussion is illuminating, with regard to our changing viewpoints of sexual attractions, and whether these were considered normative or pathological. Sigmund Freud was one of the earliest proponents of the idea that sexuality rages on a continuum and has environment influences. He expressed the idea that all people are innately bisexual, and that they become heterosexual or homosexual as a result of their experiences with parents and others (Freud, 1905). In a now-famous letter to an American mother in 1935, Freud wrote:

"Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation, it cannot be classified as an illness; we consider it to be a variation of the sexual function produced by a certain arrest of sexual development [emphasis added]. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them (Plato, Michelangelo, Leonardo da Vinci, etc.). It is a great injustice to persecute homosexuality as a crime, and cruelty too.... (reprinted in Jones, 1957).

Freud’s liberal viewpoints were the target of much debate in the psychoanalytic world, with supporters and dissenters. Many of the later relegated homosexuals to a small minority, thus validating that it was an aberration. Kinsey’s (1948) research challenged this, showing that 10% of the population has either engaged in or fantasized a about same- sex attraction.

As liberal as some aspects of Freud’s approach was, psychoanalytic theories still represented the viewpoint that homosexuality was due to arrested development, the implication being that the “norm” was heterosexuality.

Hooker

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Evelyn Hooker (1957) is credited with publishing the first empirical research to challenge the prevailing psychiatric assumption that homosexuality was a mental illness. Her work is considered the cornerstone subsequent research that ultimately led to removal of "homosexuality" from the Diagnostic and Statistical Manual of Mental Disorders. Hooker administered projective tests to 30 homosexual males and 30 heterosexual males matched for age, IQ, and education. Independent raters attempted to say whether they could distinguish sexual orientation from responses and were unable to do so. The evaluator’s adjustment ratings of the homosexuals and heterosexuals did not differ significantly. Hooker concluded that homosexuality is not inherently associated with psychopathology. These resulted were subsequently replicated.

DSM Diagnoses

In 1973, the American Psychiatric Association removed the diagnosis of “homosexuality” from the DSM-III. Subsequently, a new diagnosis, ego-dystonic homosexuality, was created for the DSM's-III (1980). The criteria for ego dystonic homosexuality was (1) a persistent lack of heterosexual arousal, which the patient experienced as interfering with initiation or maintenance of wanted heterosexual relationships, and (2) persistent distress from a sustained pattern of unwanted homosexual arousal. Therapy often centered on so-called “reparative” or “conversion” therapies (American Psychiatric Association, 2000). Behavior therapists tried a variety of aversion treatments, such as inducing nausea, providing electric shocks; or having the individual snap an elastic band around the wrist when the individual became aroused to same-sex erotic images or thoughts. Such efforts were especially prevalent during the 1960s and 1970s

In 1986, the diagnosis of ego-dystonic homosexuality was removed entirely from the DSM- IIIR. Following the removal of this diagnosis, behavior therapists became increasingly concerned that aversive therapies were inappropriate, unethical, and inhumane (see Davison, 1976, 1978; Davison & Wilson, 1973; M. King, Smith, & Bartlett, 2004; Martin, 2003; Silverstein, 1991, 2007). Such therapies reinforce stereotypes and contribute to a negative climate for lesbian, gay, and bisexual persons.

Theories of Normal Variation

Drescher (2015) also describes what he calls “theories of normal variation.” These theories form the basis of statements by professional organizations including the APA (2008).

The consensus of the behavioral and social sciences and the health and mental health professions is the belief that homosexuality is a normal variation of human sexual and romantic orientation. In a report of the American Psychological Association task force on appropriate therapeutic responses to sexual orientation states “Same-sex sexual attractions, behavior, and orientations per se are normal and positive variants of human sexuality—in other words, they do not indicate either mental or developmental disorders.”

According to the American Psychological Association (2008):

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• Research has found no inherent association between homosexual orientation and psychopathology. • Both heterosexual behavior and homosexual behavior are normal aspects of human sexuality. • Lesbian, gay, and bisexual orientations represent normal forms of human experience, and are normal forms of human bonding.

The same report states that helpful responses of a therapist treating an individual who is troubled about her or his same-sex attractions include helping that person actively cope with social prejudices against homosexuality, resolve issues associated with and resulting from internal conflicts.

The Coming Out Process

Case Vignette Rick is a 16-year-old high school student who attends school in a small town in the Midwest. While he has dated several young women, he is aware that he is not really “turned on” by them. Rick has been aware of an attraction to a male student he recently met, but is concerned about pursuing the relationship in any way. He has recently been able to talk with his mother about this, and she counseled him that his sexual orientation was still forming, and this was likely a “phase.” Rick is unsure how he feels now.

Renee, a 32-year-old lesbian woman is from a conservative religious family. A major source of stress between her and her partner, Kay, is the fact that Renee has not disclosed their relationship to her parents. Although her parents are good about inviting Renee’s “roommate,” Kay to family occasions, they do not “know” that Renee is lesbian. Kay has begun to challenge this, and Renee feels conflicted.

By this point in the training material, it is evident that most gay, lesbian and bisexual people have experienced prejudice and discrimination. This has been cited as a key reason for the conflict that some people may experience around sexual orientation. Confusion and an inability to fully embrace one’s sexual orientation is also influenced by inaccurate knowledge, lack of role models, minimal opportunity to socialize with others who identify similarly or concurrent opposite-sex attractions. (Canadian Pediatric Society, 2008). It may be a challenge for gay and lesbian youth and adults is to develop a healthy and integrated identity in the context of negative stereotypes and prejudice, sometimes without family or societal support.

Research has shown that feeling positively about one’s sexual orientation and integrating it into one’s life fosters positive emotional adjustment. This often involves disclosing one’s identity to others. This often increases the availability of social support, and connection with the gay and lesbian community, which enhances psychological functioning.

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The phrase “coming out” is used to refer to several aspects of lesbian, gay, and bisexual persons’ experiences: self-awareness of same-sex attractions; the telling of one or more people about these attractions; widespread disclosure of same-sex attractions; and identification with the lesbian, gay, and bisexual community. Experts in lesbian, gay, and bisexual adjustment feels that coming out is often an important psychological step for many people. Research has shown that feeling positively about one’s sexual orientation and integrating it into one’s life fosters greater wellbeing and mental health (APA, 2008).

This is not a single event, but a life-long process, and may begin at any age. Although there are many “models” of the coming out process, it is not exactly the same for every person. According to the APA (2008), lesbian, gay and bisexual people benefit from being able to share their lives with and receive support from family, friends, and acquaintances. When lesbians and gay men feel they must conceal their sexual orientation, they report more frequent mental health concerns than do lesbians and gay men who are more open. Studies have consistently shown that suppression (hiding secrets), is related to adverse health outcomes and that expressing and disclosing characteristics of the self improve health by reducing anxiety and resulting in assimilation of the revealed characteristics (Meyer, 2013) and the ability to positively affiliate with other similarly stigmatized persons.

In writing about stigma, Smart and Wegner (2003) describe the burden of hiding one’s stigma in terms of the resultant constant preoccupation with hiding. They describe the inner experience of the person who is hiding a concealable stigma a “private hell.” There are a number of reasons that people choose to conceal their sexual orientation, but these have in common such concealment being a form of protection.

According to Meyer (2013) such secrecy may be due to fear of discrimination and a need for self-integrity. Lesbian, gay and bisexual people may adopt strategies that range from passing (lying to be seen as heterosexual) covering (involves censoring clues about one’s self so that homosexual identity is concealed), being implicitly out, ( telling the truth without using explicit language that discloses one’s sexual identity) and being explicitly out. Thus some people come out fully, selectively or not at all.

Models of Gay and Lesbian Identity Development

Cass Model

Vivienne Cass (1979) developed the first formal model of gay identity. Her model is based on the idea that the acquisition of a homosexual identity is a developmental process resulting from the interaction between the individual and his or her environment. Cass identifies six stages of perception and behavior that starts out with little awareness or acceptance of a homosexual identity and the progress to a final stage in which one’s homosexual identity is integrated. These stages are identity confusion, identity comparison, identity tolerance, identity acceptance, identity pride and identity synthesis.

Although not the same for everyone, there aspects to the coming out process that Cass identifies and that are fairly universal. The process generally begins with the self-

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120 recognition a person is attracted to members of the same sex. A person may experiences “crushes,” as a child or adolescent, or may know that they are not attracted to the same people as peers. These feelings may result in confusion or in attempts to deny or repress attractions. This may be met with anxiety, or trying to “be” heterosexual. Many gay men and lesbian women report dating others of the opposite sex, but often state that the experience was not fulfilling. There may also be sexual experimentation, such as when a person is intoxicated and freer in sexual expression. There is a general sense of uncertainly about one’s sexuality. Cass calls this stage identity confusion.

In the identity comparison stage, the person accepts the possibility of being gay or lesbian and examines the wider implications of that tentative commitment. They may explore disclosure in a limited or “joking” sense, but have not yet taken the step of full commitment to their sexuality. Oftentimes, gay, lesbian, and bisexual people experience some degree of social alienation during this stage. This is part of the process of acknowledging one’s sexuality as different from the mainstream.

Cass (1979) calls the next state of the coming out process identity tolerance. During this time acknowledgment and acceptance of one's sexual orientation develops. There may be some grief over the loss of a traditional heterosexual life. Gay and lesbian people may be fairly closeted at this point. However, most seek out information about being gay, and may begin to interact with other gay, lesbian and bisexual people. Such personal experience may begin to build a sense of community.

In the identity acceptance stage, the person accepts, rather than tolerates, his or her homosexual self-image. There is often increased contact with gay and lesbian subculture and less with heterosexuals. A person may also feel increased anger toward anti-gay society. The hallmark of the identity acceptance stage is greater self-acceptance.

Identity pride is Cass’s next stage. At this point, a the person, who has accepted their sexual orientation, is fully immersed in gay and lesbian subcultures. There may be less interaction with heterosexuals, and a person may view the world divided as "gay" or "not gay". People who are here in their identity development may be more confrontational with the established heterosexual world; for example -Disclosure to family, co-workers

The final stage is called identity synthesis. As the name implies, this is the stage in which the person’s gay or lesbian identity is integrated with other aspects of their identity. There is greater recognition that there are supportive heterosexual people in their life. In this stage, sexual identity still important but not primary factor in relationships with others.

D’Augelli “Homosexual Lifespan Development Model”

Another frequently used model of development is D’Augelli (1994) Homosexual Lifespan Development Model.” According to D'Augelli, identity is shaped in sociocultural contexts, unlike Cass’ model which was predominately based on internal psychological processes. As

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121 a person’s awareness of social circumstances changes over time, the individual's identity development will also change. An important aspect of this model involves the person’s sociocultural context and his or her perception of safety. D'Augelli stated that other models of identity development reinforce heteronormativity (the assumption, in individuals or in institutions, that everyone is heterosexual), and that lesbian, gay, and bisexual identity development is often socially conditioned by fear and shame.

The components of D’Augelli’s model, which center around coming out, include:

• Exiting Heterosexual Identity— Realization of an identity other than what society has deemed “normal.” Recognition that one’s feelings and attractions are not heterosexual. May involve telling others that one is gay, lesbian or bisexual.

• Developing a Personal LGB Identity Status—The process of coming out to one’s self and identifying to one's self as gay, lesbian, or bisexual. challenge internalized myths about what it means to be gay, lesbian, or bisexual. Developing a personal identity status must be done in relationship with others who can confirm ideas about what it means to be LGB.

• Developing a LGB Social Identity—The process of sharing a gay, lesbian, or bisexual identity (or coming out) to friends. Creating a support network of people who know and accept one’s sexual orientation.

• Claiming an Identity as a LGB Offspring—The process of coming out to parents or guardians. D’Augelli noted that establishing a positive relationship with one’s parents can take time but is possible with education and patience.

• Developing a LGB Intimacy Status—The process of forming intimate relationships with people of the same sex. “The emergence of personal, couple-specific, and

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community norms.” D’Augelli notes that templates for LGB intimacy are often difficult to find.

• Entering a LGB Community—Coming out in multiple areas of one’s life and being active within the community, including going to events, bars, clubs, organizations, etc. This may also include social action. Some people never integrate this aspect of identity formation.

McCarn-Fassinger “Lesbian Identity Development”

McCarn-Fassinger (Fassinger, 1996) developed the “Lesbian Identity Development” Model, which looks at both identity development from a personal perspective and a group perspective. McCarn-Fassinger subsequently extended the model to include men.

McCarn-Fassinger proposed two processes of identity development: Individual sexual identity relating to one's internal awareness and acceptance of self, and group membership identity relating to one's role in the gay/lesbian community. Both processes consist of four sequential phases, in which an individual can reside in a different phase for each process:

Phase 1: Awareness: perceiving oneself as different from other people. This involves individual awareness of feeling or being different (e.g., “I feel pulled toward women in ways that I don’t understand”) as well as group awareness of different sexual orientations in people (“I had no idea there were lesbian/gay people out there.”).

Phase 2: Exploration: investigating feelings of attraction for individuals of the same sex. This phase involves individual exploration of strong, erotic feelings for people of the same sex (or a particular person of the same sex) and group exploration of one’s position regarding lesbians/gays as a group (both attitudes and membership).

Phase 3: Deepening/Commitment: internalizing the sense of self as a gay or lesbian person. This phase involves individual commitment to self-knowledge, self- fulfillment, and crystallization of choices about sexuality and Group Commitment to personal involvement with referenced groups, with awareness of oppression and consequences of choices.

Phase 4: Internalization/Synthesis: incorporating one's sexual identity into one's overall identity. This phase involves individual synthesis of love for women or men, sexual choices, into overall identity as well as group synthesis of identity as a member of a minority group, across contexts.

Tips for Working With Gay, Lesbian and Bisexual Clients

While there are many excellent therapists, it is not a given that everyone can be equally effective with gay, lesbian, and bisexual clients. Here are some “tips”

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• For all clients, avoid making assumptions about sexual orientation or sexual practices, including assumptions of heterosexuality.

• Assess your own prejudices. If you think that you cannot enter into a therapeutic relationship with a client without bias, do not do so. It also helps to remember that therapists all have biases. Be aware of your countertransference, and above all, do no harm.

• Disclose, even prior to an initial meeting. If a gay or lesbian potential client asks for your sexual orientation, it is fine to ask why (e.g., have they had negative experiences in the past) and also fine to describe your own experience in working with gay and lesbian patients.

• Initiate open discussion of sexual history. Education and counseling should be available to prevent the spread of HIV, HPV and STIs, especially in youth.

• Continue to educate yourself on issues related to sexuality, prejudice and minority stress.

• Know local resources for gay and lesbian clients and their families (some resources are listed below).

• Ask clients about their own experiences of discrimination and prejudice. Use open- ended questions. Know myths about homosexuality in order to better challenge internalized homophobia.

• Choose words carefully. Observe and reflect language and terminology used by the client. Some clients may be offended by certain word choices, such as sexual preference (a preferable word may be sexual or romantic orientation) and the term “alternative lifestyle” may be equally offensive. Use inclusive, gender-neutral language on forms and in interviews.

• Understand the stages of the coming out process and theories of identity development. Never force your own beliefs about disclosure on others. Many clients, however, prefer direct feedback on this and other issues.

• Although beyond the scope of this material, it is also important to understand differences between gay and lesbian couples and gay and lesbian parenting issues.

• Be aware of practice guidelines for your professional affiliation.

Resources

Political Human Rights Campaign (HRC)

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National LGBTQ Task Force

Bisexual Bisexual Resource Center

Youth Gay, Lesbian & Straight Education Network (GLSEN) Safe Schools Coalition The Trevor Project

Family Matthew Shepard Foundation Out & Equal Parents, Families and Friends of Lesbians and Gays (PFLAG)

Chapter 9 Topics in Human Sexuality: Sexuality and Childhood Sexual Abuse

Case Vignette

Maria is a happily married 27-year-old woman. She and her husband, Jeff, share many common interests and values. They would like to begin their family, however, this presents a problem. Maria is a survivor of childhood incest. Her grandfather, who is now deceased, was the person responsible. Although Maria would like to be sexual with Jeff and tries to do so, he is acutely aware of her discomfort during lovemaking. He has stopped trying to initiate sexual intimacy because he feels like “a perpetrator.” Maria is upset and unhappy about the situation.

Child sexual abuse is the involvement of children or adolescents in sexual activities that they do not fully understand and can include exhibitionism, fondling, oral-genital contact, and rectal or vaginal penetration. Most mental health professionals are acutely aware of the profound effects of child sexual abuse. Childhood sexual abuse and incest have become increasing areas of concern for clinicians. This is in part due to the prevalence rates of abuse: By adulthood, 26% of girls and 5% of boys experience sexual abuse (Melmer & Gutovitz, 2017). Females between the ages of 12 to 24 have been shown to be the demographic at highest risk of becoming victims of sexual assault and rape. Greater than 50% of the rapes targeting women happen during childhood, and between 5% and 25% of adults report being victims of child sexual abuse. Fewer than half of all sexual assaults are ever reported to the police (Melmer & Gutovitz, 2017). It is believed that many statistics on child sexual abuse and neglect vastly underestimate its incidence. This is particularly true for men, who often remain silent about their abuse.

Childhood sexual abuse presents many therapeutic challenges. Childhood sexual abuse is a betrayal of intimacy. As such, relational problems of many types may result from past abuse. One of the primary areas in which this is seen are within sexual relationships.

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Childhood sexual abuse often prevents survivors from achieving satisfying sexual relationships.

Understanding the impact of childhood sexual abuse and its effects on sexuality will help mental health professionals to better counsel individuals and couples.

Objectives:

• Define sexual abuse • Discuss the non-sexual effects of abuse • Describe myths of male victimization • Discuss effects of trauma and sexual abuse connected to adult sexuality • Describe techniques that can be used in counseling abuse survivors • Define counseling techniques including use of sexual genograms/sensate focus

Definition of Childhood Sexual Abuse, Incest and Teen Dating Violence

Case Vignette

Karen is a 35-year-old woman who reports a long history of childhood sexual abuse, first by her grandfather beginning at age 6, and later with a series of abusive boyfriends and men. Most recently she has been involved with Rick, who she describes as sexually adventurous. He often demands that she try sexual acts that she does not wish to undertake, such as anal sex. Karen is seeking to leave this relationship, but feels hopeless that any relationship can be loving or truly consensual.

The American Medical Association defines child sexual abuse as "the engagement of a child in sexual activities for which the child is developmentally unprepared and cannot give informed consent” (American Medical Association, 1992). The most significant feature of child sexual abuse is that the dominant position of an adult allows him or her to coerce the child into sexual activity (American Psychological Association, 2001). Child sexual abuse may include fondling a child's genitals, masturbation, oral-genital contact, digital penetration, or vaginal and anal intercourse. Child sexual abuse is not solely restricted to physical contact; such abuse could include noncontact abuse, such as making a child watch pornography or look at an adult’s genitals. Sexual abuse may also include abuse by a child’s peer, especially when there is a significant incongruity in age, development, or size.

Although all forms of sexual abuse are damaging, incest, sexual abuse perpetrated by a family member is particularly destructive and painful. Incest is defined as any sexual activity between close blood relatives who are forbidden by law to marry (Kellog, 2005). Among the various types of incest, father-daughter incest is the most common, followed by the other types like brother-sister, sister-sister, and mother-son incest (Soron, 2016). Incest is frequently underreported, due to the stigma surrounding it. The results of incest and

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126 other forms of sexual abuse may not be evident until the survivor reaches adulthood and seeks his or her own relationships Herrenkohl et al., 2013, Kim-Cohen et al., 2006).

Teen dating violence, another common experience included within the realm of childhood sexual abuse, is defined as abuse, harassment, or stalking of an adolescent between 12 years and 18 years of age in the context of a past or present romantic or consensual relationship (Mulford & Blachman-Demner, 2013). Studies demonstrate that approximately one in five female adolescents suffer physical and/or sexual violence by her partner during a dating relationship (Rizzo et al., 2010).

Risk Factors for Child Sexual Abuse

Many factors increase the risk of child abuse, including individual, family, environmental, and social factors. Children that have a physical disability, mental disability, or other behavioral disorders are also at higher risk for abuse, especially if the family lacks the socio-economic resources to assist them.

The following factors may increase the risk of abuse:

• Abused as children • Attachment problems • Chronic behavior problems • Divorce • Frequent moving • Hostile environment • Isolation from friends and family • Low self-esteem • Medical problems • Mental or physical disability • Mental health problems • Nonbiological relationships • Poor social network • Poverty • Prematurity • Punitive child-rearing styles • Substance abuse • Unemployment • Unrealistic expectations • Young parents

Situational Triggers: • Acute environmental problems • Argument • Substance abuse • Perceived need for discipline/punishment

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Effects of Trauma and Sexual Abuse

Case Vignette

Kathy, a 29-year-old sexual abuse survivor has been in an out of treatment for a severe eating disorder since childhood. The bulimia began as a teen and after disclosing that her older brother had molested her. Kathy’s psychological problems have prevented her from holding down a consistent job, and her social network is quite limited as she is often seen as “draining” and “needy” in relationships. Her sexual relationships mirror her problems with food — she is restrictive and not interested in sexual relationships sometimes, and has other times when she is promiscuous, “binging” on sex.

Childhood sexual abuse is damaging. The effects of sexual abuse include those related to emotional/psychological health and physical health. A brief discussion of these effects is included because it is important to see the survivor holistically and not to focus only on relational and sexual problems. Although many of the things described below are not immediately related to adult sexuality they have less direct effects.

Sexual abuse impacts the survivor’s sense of safety and well being. As a result, those who have been sexually victimized are more likely to develop psychological problems. The most common of these are disorders along the depressive spectrum, including major depressive disorder and dysthymia (Molnar, Buka & Kessler, 2001; Williams et al., 2015), suicidality (Chatzittofis, et. al, 2017), intimate partner violence (Williams et al., 2015), Post Traumatic Stress Disorder (PTSD) (Afifi et. al, 2008) and anxiety disorders (Levitan, et al., 2003). Memories of childhood sexual abuse can be highly distressing to the patients and are associated with a broad spectrum of aversive emotions that include anxiety, helplessness, anger, and sadness (Kleim, Graham, Bryant, & Ehlers, 2013).

Victims of child sexual abuse are also at higher risk for developing addictive behaviors including substance abuse problems (Day, Thurlow, & Woolliscroft, 2003; Clum et al., 2012)) such as tobacco, alcohol, and illicit drugs (Melmer & Gutovitz, 2017) and eating disorders (Kimber et al., 2017; Afifi et al., 2017). There are many reasons for this. Substance abuse combined with eating disorder symptoms results in emotional numbing and may be a way to modulate emotions or to decrease painful feelings. People who develop eating disorders often describe similar functions of the disorder. Survivors are often uncomfortable with their bodies and do not want others to see them. This certainly impacts their abilities to be sexual with partners and those with eating disorders may eschew sexual experiences due to these body image concerns (Potki et al., 2017).

Cook et al. (2016) describe what they term avoidant coping behaviors as common sequalae of sexual abuse. Avoidant behaviors include dissociation, binge–purge eating, substance use, self-mutilation, suicide attempt, and risky sexual behavior. The researchers state that although tension-reducing behaviors such as sexual activity and substance use can have immediate stress-diminishing benefits, risky sexual practices with multiple partners and

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128 inconsistent condom use can have negative long-term effects such as increased risk of sexually transmitted infections.

Researchers have established that there are elevated rates of childhood sexual abuse in borderline personality disorder patients (Menon et al., 2016) and such research suggests a role of childhood trauma in the form of sexual abuse in developing borderline symptoms in adulthood. In the Menon et al. (2016) study, 44.44% of the patients had some form of sexual abuse in their childhood and the connections between child sexual abuse in earlier years of life was specifically associated with borderline personality disorder compared to child sexual abuse in later years. Merza et al. (2017) also found an association between childhood adversity, including sexual abuse, and non-suicidal self-injury, common in individuals with borderline personality disorder.

Some abuse survivors also exhibit somatic concerns such as migraine headaches, other aches and pains, asthma, and gastrointestinal upsets. Some gastrointestinal and respiratory problems may symbolically relate to the abuse, such as nausea being related to forced oral sex. Other physical symptoms include tension, heart palpitations, trembling, poor sleep, sweating and loss of appetite. Fibromyalgia and Chron’s disease are also found more frequently in trauma survivors (Miller, 2005). When physical problems occur, survivors are less likely to show interest in sexual intimacy. It is difficult to want to be sexual, for example, when a person is experiencing a flare up of Chron’s disease.

In addition to the research cited above, another major source of data is the Behavioral Risk Factor Surveillance System survey, which looks at adverse childhood experiences (ACEs) among a large sampling of US adults. The data were analyzed on 48,526 U.S. adults from five states. Exposures included psychological, physical, and sexual forms of abuse as well as household dysfunction such as substance abuse, mental illness, violence, and incarceration. Main outcome measures included risky behaviors and morbidity measures, including binge drinking, heavy drinking, current smoking, high-risk HIV behavior, obesity, diabetes, myocardial infarction, coronary heart disease, stroke, depression, disability due to poor health, and use of special equipment due to disability (Campbell, Walker& Egede, 2016).

Male Survivors

Case Vignette

Curt, a 22-year-old man who is currently involved in a drug and alcohol treatment program, recently disclosed a history of sexual abuse, occurring between himself at age 10, and a female babysitter who was 16. While he initially insists that the “relationship” was consensual and not damaging in any way, since becoming substance-free Curt has begun to better understand the far-reaching effects of the abuse, and how it as impacted his current relationships. In particular, Curt has a history of seeking sexual encounters with women much older than him, and who are generally unavailable. This has not proven to be successful, and he feels that he cannot have a “normal” (i.e., age-appropriate) relationship.

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National Crime Victimization Survey reports that 9% of men have experienced sexual assault. This study suggests that men encounter assault by women and men relatively equally: about 43% of sexual assaults against men were perpetrated by women, and 51% by men (Weiss, 2010).

Although many of the issues described in the section above are pertinent to male and female survivors of sexual abuse, there are some special issues to consider when working with male survivors.

While male survivors of sexual abuse do not receive the same degree of attention as female survivors it is important to note the detrimental effects of sexual abuse on men. Williams et al. (2016) posits that male sexual abuse victims are often almost invisible. Johanek (as cited in Renken, 2000) describes three myths of male victimization:

• “Real men” would fight or resist the abuse • Sexual response to abusive behaviors “shouldn’t happen.” • Offenders are homosexual and forever “taint” the victim.

Males, especially those that abused by other men, tend to struggle with issues of homophobia and vulnerability and to engage in sexually risky/acting out behaviors. They may direct feelings of anger about the abuse outwardly or engage in sexual acting-out behaviors. While female perpetrators are often viewed as less detrimental than male perpetrators this is a myth. Sexual abuse of men by women, is equally damaging.

Effects of Trauma and Sexual Abuse Connected to Adult Sexuality

Case Vignette

Joe is a married father of two. He describes a history of sexual molestation by a male clergyman when he was 9. Joe is vocal in his homophobia and expression of hatred for gays and lesbians. It came as a shock to everyone when Joe was arrested for soliciting an uncover officer posing as a male prostitute. Joe is ashamed of his behavior and fearful that he will continue to act out in this compulsive way.

Marianne is a newly married women in her mid-twenties who has a history of sexual abuse (coercive fondling) by an older male cousin. While she has tried to put this behind her, she is struggling. Marianne describes herself as “asexual,” and while she knows that her lack of interest in sex is hurtful to her husband, she feels that she cannot change this. When pressed, she states that she feels “dirty” when she engages in sexual intimacy with him, and she has secretly begun purging to allow herself to tolerate sexual relations. In exploring her sexual self-concept, Marianne’s descriptors further include: cold, negative, and disgusting.

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It is no surprise that childhood sexual abuse has an impact on adult sexuality. Just as survivors of childhood sexual abuse exhibit many different types of concerns that relate to the abuse, there is no single presentation with regard to adult sexuality.

In looking at the proceeding discussion, an interesting lens through which to look at sexuality in adult survivors is the idea of sexual self-concept, the core of sexuality (Potki et al., 2017; Deutsch, Hoffman &, Wilcox, 2014). Mental and emotional aspects of sexual wellbeing are the important aspects of sexual health. Sexual self-concept is defined as the cognitive perspective concerning the sexual aspects of ‘self’ and refers to the individual’s self-perception as a sexual being. Sexual self-concept is multi-dimensional and dynamic, and is developed based on the individual’s understanding of his/her personal sexuality (Deutsch, Hoffman &, Wilcox, 2014). Sexual self-concept originates from past experiences to present sexual experiences.

The development of sexual self-concept is influenced by multiple events in individuals’ lives including biological, psychological and social factors. In the psychological category, the impact of body image, sexual abuse in childhood and mental health history are present. Individuals with a history of childhood sexual abuse, may have a more negative sexual self- concept (including sexual anxiety, monitoring sexuality, the fear of sexual relationships and sexual depression). This is in contrast with positive aspects of sexual self-concept, including sexual self-efficacy, sexual consciousness, sexual optimism, motivation to avoid high-risk sexual relationships, self-blame in case of sexual problems, management of sexual affairs, sexual self-esteem, sexual satisfaction, prevention of sexual problems, use of contraception, avoidance of high-risk sexual behavior and internal control of sexual problems (Potki et al., 2017). Survivors of childhood sexual abuse may develop maladaptive beliefs and attitudes towards sexuality, which cause survivors to process sex-related information through a threatening lens (Lorenz & Meston, 2012).

Meston, Rellini & Heiman (2006) looked at female survivors of child sexual abuse using measures of adult sexual function, psychological function (i.e., depression and anxiety), and sexual self-schemas. The primary purpose of the study was to examine whether differences existed between women with and without a history of sexual abuse in the way that they viewed themselves as a sexual person and, if so, whether such differences mediated the link between early unwanted sexual experiences and later adult sexuality. Survivors were found to view themselves as less romantic and passionate than women who were not abused. In particular, survivors showed an inverse relationship between romantic/passionate sexual self-schemas and negative sexual affect during sexual arousal. The relationship between abuse and negative sexual affect was independent from symptoms of depression and anxiety, suggesting that the impact of sexual abuse on sexual self-schemas may be independent from the impact that the abuse may have in other areas of the survivor's life.

In looking more broadly at some more of the specific effects of sexual abuse on sexuality in the adult survivor, the effects of sexual abuse on adult sexuality fall into one of the following categories:

• Difficulty establishing intimate relationships

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• Avoidance behaviors • Intense emotional reactions or numbing • Physical problems related to sexuality • Body image disturbance that impacts sexuality • Intrusive thoughts or fantasies • Sexually risky behaviors • Hypersexual behaviors

Establishing Intimacy

In addition to problems with sexual intimacy, survivors of sexual abuse also experience difficulties in close relationships. Bass & Davis (2015) define intimacy as a “bonding between two people based on trust, respect, love, and the ability to share deeply.” It is no question that sexual abuse damages a person’s ability to trust others. Many see trust as an all-or-nothing experience, rather than being able to develop trust in another person. In relationships, trauma survivors may be hypervigilant to any sign that the person is not trustworthy. Child sexual abuse can result in insecure or disoriented/disorganized attachment patterns (Menon et al., 2016). Although some of these factors can be partially protective, especially hypervigilance, it also impedes the ability to establish a relationship, especially one that will be sexual (Gardner, McCutcheon, & Fedoruk, 2017; Martinson et. al, 2013). . Another common impediment to establishing intimacy is confusing the past with the present (Nasim & Nadam, 2013). Although a partner may loosely share some characteristics with an abuser - which does that mean that he or she is abusive. A survivor may react by distancing, or by merging — creating a state of dependency. Neither of these extremes is solid ground for an intimate or a sexual relationship.

An interesting take on intimacy can be found in a study by Lorenz and Meston (2012). These researchers sought to better understand the link between childhood sexual abuse and adult sexual functioning and satisfaction by examining the cognitive differences between women with and without sexual abuse histories. They used the Linguistic Inquiry Word Count, a computerized text analysis program, to investigate language differences between women with and without abuse histories when writing about their daily life (neutral essay) and their beliefs about sexuality and their sexual experiences (sexual essay). In comparing these groups, the researchers found that women who reported sexual abuse used more intimacy words and more language consistent with psychological distancing in the sexual essay than did non abused women.

Additionally, survivors of childhood sexual abuse report significantly lower satisfaction with their sexuality (Rellini & Meston, 2007), which in turn is associated with lower marital or relationship satisfaction (DiLillo, Peugh, Walsh, Panuzio, Trask, & Evans, 2009) and higher rates of divorce (Nelson, et al., 2002).

Avoidance Behaviors

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Sexual abuse survivors may also go to lengths to avoid sexual expression and intimacy. This may manifest in lack of sexual interest or inhibited sexual desire. Maltz (2001) identifies this as the most common sexual problem in this population. Sometimes sexual avoidance behaviors are hidden by other, more overt behaviors, such as an abuse survivor who self- injures or overeats with the intention of making herself unattractive to a potential partner (Merza et al., 2017). This may be due to fears about sexual intimacy which developed in childhood. There may also be strong negative reactions when touched. Some abuse survivors approach sex only as an obligation.

25. Vaillancourt-Morel et al. (2015) looked at avoidant and compulsive sexual behaviors in male and female survivors of childhood sexual abuse. They studied 686 adults currently in a close relationship. Prevalence of childhood sexual abuse was 20% in women and 19% in men. The researchers found that childhood sexual abuse was associated with more sexual avoidance and sexual compulsivity, which, in turn, predicted lower couple adjustment.

Intense Emotional Reactions Or Numbing

Another common sexual problem for abuse survivors is the intensity of emotional reactions when engaging in sexual behaviors (Rellini et al., 2012). Survivors often report negative reactions, such as fear, guilt, anger or disgust. These feelings are generally rooted in the past rather than the present and are one of the most challenging things for couples to work on. Other abuse survivors describe a sense of emotional numbing, such as in the first vignette presented in this material, or a feeling of being dissociated or distant during sexual activities. Another difficult experience is that of having a flashback during sexual experiences.

Physical Problems Related To Sexuality

With the close connection between mind and body, it makes sense that those with a history of abuse may experience physical problems related to sexuality. Adult abuse survivors often report difficulties with sexual arousal (in women, lack of lubrication, in men, inability to develop or maintain an erection), difficulty with intercourse (muscle pain, spasm, fear of penetration, vaginismus), difficulty experiencing orgasm (anorgasmia), or difficulty averting orgasm (premature ejaculation in men, rapid orgasm in women). Some of these problems, such as lack of ability to achieve orgasm, may be related to messages that trauma survivors received from their abusers, such as that they are somehow sexually inadequate (Reissing, et al., 2003). Women with histories of childhood sexual abuse also reported lower sexual desire, inhibited sexual arousal and orgasm, and higher sexual pain than women without such histories in both clinical and community samples (Najman et al., 2005).

Body Image

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Body image is the attitude and perception one’s own body. Body image includes many components: thoughts and beliefs one holds, understanding of how others view us, feelings about the body, kinesthetic awareness and responsiveness. While these components may be related to physical appearance, this relationship may be indirect, especially for a person that has been through sexual abuse. For all of us the goal of body image treatment is finding a place of acceptance and ownership of the body. Childhood sexual abuse robs the person of that ability and negatively affects body image (Castellini et al., 2016; Kravvariti & Gonidakis, 2016).

Ackard, Kearney-Cooke & Peterson (2000) studied the connection between body image and sexuality. The reseachers found that women more satisfied with body image reported more sexual activity, orgasm, and initiating sex, greater comfort undressing in front of their partner, having sex with the lights on, trying new sexual behaviors, and pleasing their partner sexually than those dissatisfied. Women with better body image reported less self- consciousness, less focus on physical attractiveness, and more positive relationships with others and overall satisfaction. Body image was also predictive only of one's comfort undressing in front of partner and having sex with lights on. Other things associated with healthier body image was frequency of sex and orgasm, initiating sex, trying new sexual behaviors, and confidence in giving partner sexual pleasure.

Thus the study described above shows that a person’s evaluation of body image can affect interests and experiences of the person during sexual activities (Potki et al., 2017). Dissatisfaction with body image hinders sexual behavior and interferes in the quality of sexual experiences and sexual performance is related to better sexual self-concept and less anxiety and worries about body image (Cash, Maikkula & Yamamiya, 2004). Thus there is a relationship between body image and sexual self-concept.

26. Dyer, Feldmann & Borgmann (2015) conducted a study to assess the association between traumatic experiences and emotions such as anxiety, shame, guilt, disgust, and anger. For patients who have experienced child sexual abuse, these emotions might be triggered by perceptions of their own body. Results suggested that specific areas of the body are associated with trauma and linked to highly aversive emotions. In post-traumatic stress disorder patients, the areas associated with highly negative emotions were the pubic region and inner thighs. Thus, the patient's body may act as a trigger for traumatic memories.

Intrusive Thoughts Or Fantasies

Post-traumatic stress disorder (PTSD) is characterized by symptoms that include intrusive or distressing thoughts, nightmares, and flashbacks derived from past exposure to traumatic events. While not every sexual abuse survivor has PTSD, many describe intrusive thoughts or fantasies about sex, such as fantasies or the reality of sexual pleasure being linked to pain. They may also fantasize about being in power or control during sex or other types of aggressive sexual behavior. Intrusive thoughts and fantasies are defenses, and require delicacy on the part of the counselor.

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Sexually intrusive thoughts create somewhat of a diagnostic conundrum as they are a component of obsessive compulsive disorder (OCD) with sexual obsessions affecting 13% to 21% of individuals with OCD at any given time (Pinto et al., 2008). While not every person with obsessive compulsive disorder has OCD, studies have demonstrated some connection. For example, Caspi et al. (2008) found that in a small scale sample of patient with OCD, 53.3% had a history of childhood sexual abuse. It is important during treatment to differentiate between sexual obsessions and other unacceptable thoughts, as well as other thematic variations may help guide cognitive-behavior therapy. It may also clarify important potential treatment targets, such as when conducting exposure and response prevention or cognitive therapy. Furthermore, treatment outcome requires careful consideration of each patient's particular core fears, this is especially true of abuse survivors (Wetterneck et al., 2015).

Kuyken and Brewin (2014) looked at a sample of adult women with major depression who reported childhood sexual or physical abuse. The women completed a measure of the extent to which they were experiencing intrusive memories of the abuse and their efforts to avoid these memories. The majority of women in the sample reported high levels of disturbing intrusive memories, and high levels of avoidance. Those abused women with particularly high levels of intrusions and more avoidance were also more severely depressed than both non-abused women and abused women with low levels of intrusions and avoidance. Higher levels of intrusions and avoidance were also associated with repeated childhood abuse, sexual abuse involving intercourse and sexual abuse involving a primary caregiver.

Sexually Risky Behaviors

Some survivors of sexual abuse report risky or inappropriate sexual behaviors and research has confirmed that this is one factor in influencing sexual high-risk behaviors (Arabi- Mianrood et al., 2017). This may include sexual compulsivity, promiscuity, or acting-out behaviors. These indiscriminate sexual behaviors may actually be accompanied by a lack of physical pleasure. Another sequalae of sexual abuse may be sexual behaviors such as exotic dancing or prostitution. This is often seen in situations in which a child was rewarded for sexual favors, and gained esteem and power through these rewards.

Many survivors have difficulty setting boundaries, especially those of a sexual nature, and may be unable to “say no” to sex, even when they do not desire it. Boundary-setting and communication are key targets of counseling.

In one study of men who have sex with men (Williams et al., 2015), researchers found that experiences of childhood sexual abuse were associated with sexual revictimization. They also reported negative sexual health outcomes, with men who have sex with men reporting higher childhood sexual abuse rates than the general male population. They were more likely than men without childhood sexual to engage in high-risk sexual behaviors, have more lifetime sexual partners, use condoms less frequently, have higher rates of sexually transmitted infections (including HIV) and to exchange sex for drugs or money. Researchers

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135 looking at straight men with a sexual abuse history have found similar evidence of sexually risky behaviors including higher rates of sexually transmitted infections including HIV (Greenberg, 2001), sex that results in pregnancy (Purcell, et al., 2004) and a higher number of sexual partners (Schraufnagel et al., 2010). Abused men are more likely to engage in condomless sex, to have earlier sexual debut and to exchange sex for drugs or money than men with no childhood sexual abuse history (Chandry et al., 2014).

Other studies (e.g., Pérez-Fuentes et al., 2013) have found a correlation between depression and sexual risk behaviors. Cook et al. (2016) also found evidence that there is a connection between sexually risky behaviors in a group of men who were forced to have sex by women. In this study the mean age of the abuse was 18.

Clum et al. (2009) looked at young women living with HIV who experienced physical and/or sexual abuse in childhood. They using the Life Story Interview with women recruited from HIV clinics. Interviews covered abuse experiences, cognitive and emotional consequences of abuse, coping strategies, and sexual behavior and relationships. Overall, these young women had complex abuse histories, often experiencing more than one type of abuse in the context of other difficult life events. Avoidance and substance use were frequently utilized as coping strategies for abuse-related distress. Young women reported sexual and relationship concerns, including avoidance of sex, sexual dysfunction, sex as a trigger for abuse memories, and difficulty establishing intimacy and trust.

Hypersexual Behaviors

Closely related to the problem of sexually risky behaviors is the connection between childhood sexual abuse and hypersexual behaviors (Chatzittofis et al., 2017; Montgomery- Graham, 2017). Hypersexual Disorder is conceptualized as primarily a nonparaphilic sexual desire disorder with an impulsivity component (Kafka, 2010). Such excesses of sexual behavior (i.e., hypersexual behaviors and disorders) can be accompanied by both clinically significant personal distress and social and medical morbidity.

Estimates of the prevalence of compulsive sexual behaviors range from about 1.7% and 4.4% of individuals and include both men and women (Grant et al., 2005). Evaluating the prevalence of hypersexual behaviors is difficult, due to the embarrassment and shame frequently reported by those with sexual compulsivity. Compulsive sexual behavior can be divided into three elements: repeated sexual fantasies, repeated sexual urges and repeated sexual behaviors (Derbyshire, & Grant, 2015). All of these elements can be related to childhood trauma. People who engage in compulsive sexual behaviors report varying responses, including tension release, numbing, and the behaviors are often followed by guilt and remorse. Behaviors can be triggered by specific mood states depression, loneliness and may be comorbid with other addictive behaviors.

As with other forms of sexual risk taking, the effects of compulsive sexual behaviors can be troubling and can interfere with many different areas of an individual’s life. Due to these sexual behaviors, individuals with sexual compulsivity may experience medical problems including unwanted pregnancies, sexually transmitted infections, HIV/AIDS, and physical

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136 injuries due to repetitive sexual activities (for example, anal and vaginal trauma) (Miner & Coleman, 2015).

Other Sexual Problems

Other sexual problems may include:

25. Low sexual desire 26. Tendency to dissociate from the body during sex 27. Compulsive masturbation 28. Sexualizing relationships and situations 29. Believing that sex is dirty or disgusting 30. Refraining from any sexual contact 31. Erection and orgasm problems 32. Confusion about sexual orientation 33. Lack of sexual knowledge

Sexuality Counseling

Counseling for couples in which one member has a history of abuse is challenging and requires specialized knowledge and skills. Long, Burnett, & Thomas (2006) describe a stage model that they term integrative couples counseling. They include the following interventions in their approach:

27. Detailed history of sexual abuse experiences 28. Reasons for seeking counseling 29. Use of sexual genograms 30. Exploration of feelings about abuse 31. Communication about sexual needs and desires 32. Exploration of guilt and shame issues 33. Journaling feelings about sexuality 34. Sensory exercises that include non-sexual touch 35. Initiation of sex/ability to decline sex 36. Relaxation techniques for anxiety 37. Direct feedback about likes and dislikes 38. Physical exercise as a way to increase control 39. Sensate focus activities and masturbation training

Sexual History and Genogram

An important part of sexuality counseling involves taking a thorough sexual history. Abuse experiences are one component of this history, and while this is important, past traumatic events are only one of the factors that counselors should consider. A thorough sexual history can be conducted as part of an interview or as a pictorial representation (sexual genograms). The sexual genogram combines aspects of the sex history with the genogram

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137 to examine the impact of the partners' family loyalties, secrets (such as sexual abuse), and scripts on their sexual functioning. The exploration process offers an opportunity to identify patterns and to target areas of needed change (Belous et al., 2012; McGoldrick, 2016).

Some of the areas to consider in a sexual questionnaire or to include in a sexual genograms are:

• Overt and covert messages regarding sexuality and intimacy • First memory of sex • Hopes/fears about sex • Sexual expectations • Extent of sexual openness now and in family of origin • Religious and spiritual influences, cultural influences on sexuality • Family secrets, including incest and abuse, unwanted pregnancies, extramarital affairs, sexual addiction, compulsive behaviors other safety issues • History with erotic material including pornography • Issues connected to sexual orientation/attraction, gender identity, non-conformance • Masturbation history • Body image history/feelings about ones body (self and close relatives, especially parents • Personal factors that affected development of selves as sexual beings • Previous sexual partners

Journaling

For many survivors of childhood sexual abuse, journaling can be an important part of sexual healing. Many of the questions in the section above can also be used as prompts for journaling. There are also a number of commercially available resources, such as Your Surviving Spirit (Miller, 2003) and Courage to Heal Workbook (Davis, 1990).

Sensate Focus

Sensate focus exercises were originally introduced by Masters and Johnson. The goal is to increase awareness of each other's needs. One of the key components of this approach is the lack of outcome orientation — the goal is to become aware of responses and feelings rather than to reach orgasm.

The first stage of sensate focus involves non-genital touch. In this stage the couple is encouraged to touch each other’s bodies and to be aware of feelings and sensations. Should the survivor become scared, overwhelmed or dissociative, the experience is terminated. Couples are told that no intercourse is allowed, and that it is a way to gain appreciation of

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138 one another. Touching, talking, and hugging are encouraged. Use of techniques such as relaxation and breathing techniques and grounding are important to counteract anxiety.

The next stage of sensate focus increases focus on touch. Genital touch is still not allowed. Couples are taught during this stage to put their hand over the other’s hand to demonstrate what is pleasurable and what is not. The experience can be stopped at any time if the survivor needs to do so.

Touch is gradually increased at the pace the couple needs and to include genital contact and finally intercourse.

Summary

Sexual abuse has lingering effects on adult behavior, relationships and sexuality. Helping abuse survivors to recognize these effects and providing a caring supportive environment in which the individual and couple can heal is key to recovery.

Chapter 10 Topics in Human Sexuality: Sexual Disorders and Sex Therapy

Introduction

Sexual disorders, such as erectile disorder in men, and orgasmic disorder in women, cause much psychological stress, both to the person with the disorder and to his or her partner. These disorders are also a primary reason that couples seek counseling. Although these disorders have been around for quite some time, psychological understanding of sexual disorders is relatively new. As with much of psychology, clinicians used Freud’s theories to explain sexual behavior. Sexual disorders were seen as pathological in nature and there was little distinction between difficulties in function and sexual “perversions.”

This changed in the 1970s with the publication of Masters and Johnson's Human Sexual Inadequacy. Unlike prior explanations of sexuality, which were based on theory, Masters and Johnson studied the psychology and physiology of sexual behavior in a laboratory. They also recorded physiological data from the sex organs during sexual excitation, and framed their findings using language that described sex as a healthy and natural activity that was also source of pleasure and intimacy. Their work is pivotal to our understanding of sexuality and sexual disorders. Many of our cognitive behavioral treatments and techniques extend from this body of work.

This chapter will define the term “sexual disorder,” and will discuss various kinds of sexual disorders. It will examine the physical and psychological causes of sexual disorders and will discuss therapies for sexual disorders.

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Educational Objectives 7. Define the term “sexual disorder” 8. List the characteristics of male erectile disorder 9. Define Premature/Early/Delayed Ejaculation, including proposed DSM V changes and use of the squeeze technique 10. Describe Male Orgasmic Disorder, and list causes and treatment 11. Describe Female Orgasmic Disorder, and list causes 12. Define Female Sexual Arousal Disorder, state common causes of the disorder, and describe treatment alternatives 13. List symptoms and causes of dyspareunia and vaginismus 14. Discuss sexual desire disorders 15. Discuss commonly used approaches to sex therapy

Defining Sexual Disorders

A sexual disorder (or sexual dysfunction) is a problem with sexual response that causes a person psychological distress. Sexual dysfunction generally refers to a difficulty experienced during any stage of a normal sexual activity as described below.

These stages of normal sexual activity are:

• Desire: Desire to participate in sexual activity, including fantasies about sexual activity • Excitement phase (initial arousal): Combines the psychological sense of sexual pleasure as well as physiological changes, in men, erections, and in women, vasocongestion in the pelvis, vaginal lubrication and expansion, and swelling of the external genitals • Orgasm: Peak of sexual activity. • Resolution phase (after orgasm): Sense of muscular relaxation and well-being. Males have a refractory period during which further erection and orgasm is not possible. Women are capable of additional stimulation and multiple orgasm.

Sexual disorder, then, involves difficulties with desire, arousal and orgasm, and in women also include sexual pain disorders (dyspareunia, vaginismus). In looking at these examples, it follows that there is a continuum; many people experience problems like this from time to time, and part of the difficulty is in determining when a problem is considered a disorder. Some factors to consider in making a judgment as to whether a disorder is problematic is the age and experience level of the person, the frequency and chronicity of symptoms, and effect on overall functioning. Another important factor in assessing sexual disorders is the determination of whether such a disorder is purely physical or whether there are psychological factors. There may also be a combination of the two.

Factors to Consider in Assessing Sexual Dysfunction

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A number of factors play a role in sexual dysfunction, including partner factors (e.g., partner health status), relationship factors, individual vulnerability factors (including negative body image and history of sexual trauma, psychiatric comorbidity, stressors, cultural and religious factors and medical factors (including normative aging). While sexual response has a biological underpinning, it is usually experienced in a relational context.

Male Erectile Disorder

Case Vignette Laura and John had been in couples counseling for a number of sessions when they began to open up about recent sexual activities. The couple had been married for 9 years, and had a satisfactory sexual relationship to this point. Recently, however, John and begun to experience difficulty sustaining an erection. Laura felt devastated, and as if she was unattractive.

One of the most psychologically distressing male disorders is erectile disorder. Erectile disorder is the persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection. Most men experience transient episodes of erectile disorder that are temporary and usually associated with fatigue, anger, depression or stressful emotions.

Basically, an erection occurs when blood fills the penis. Erections begin with a sexual signal or stimulus such as a partner’s touch, erotic visuals, sexual sounds, certain smells, fantasies or other stimuli. During arousal, the blood vessels of the penis dilate, and muscles around the penis relax, allowing for an increase in blood flow and resultant penile erection. Erectile disorder can occur at any stage during this process.

There are varying patterns of erectile disorder. Men with erectile disorder may report the inability to experience any erection from the beginning of a sexual experience, while others experience an erection that is not maintained at penetration. Other men may lose the erection during sexual intercourse, and others can only experience erection upon awakening or during self-masturbation. There are a number of causes of erectile dysfunction including drugs and alcohol, age, fatigue, certain medications, medical problems (diabetes, cardiovascular disorders) and psychological factors (stress, anxiety).

Men with erectile dysfunction should be evaluated medically to determine any physiological factors in erection problems. Sometimes erectile problems can be addressed through lifestyle changes, or the use of Kegel exercises strengthen the pelvic floor, which can lead to stronger erections and enhanced ejaculatory control or through medications such as Viagra, Cialis or Levitra.

Premature (Early) Ejaculation

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Premature ejaculation is defined as persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. Premature ejaculation is also known as rapid ejaculation, rapid climax, premature climax, or early ejaculation. When assessing for the presence of premature ejaculation the clinician must take into account factors that affect duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity. Thus, both psychological and biological factors can play a role in premature ejaculation.

Premature ejaculation is a common sexual complaint. Estimates vary, but as many as 1 out of 3 men may be affected by this problem at some time. There are a number of subtypes of this disorder, including lifelong/acquired type, and generalized/situational type.

Although we know that premature ejaculation is relatively common, one of the difficulties in establishing accurate prevalence statistics is the absence of an agreed upon definition of what timeframes constitute premature ejaculation (Beutel, 2006). The criteria for Premature (Early) Ejaculation requires that:

A. The symptom must have been present for at least 6 months and be experienced on all or almost all (75%-100%) occasions of sexual activity: Persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately one minute of beginning of sexual activity and before the person wishes it. B. The problem causes clinically significant distress or impairment. C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due to the effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Premature (Early) Ejaculation may also come with concomitant problems in sexual interest/sexual arousal.

Both psychological and biological factors can play a role in premature ejaculation. It is important to consider:

1) Partner factors (partner’s sexual problems, partner’s health status) 2) Relationship factors (e.g., poor communication, relationship discord, discrepancies in desire for sexual activity) 3) Individual vulnerability factors (e.g., poor body image, history of abuse experience) or psychiatric comorbidity (e.g., depression, anxiety, worry or performance anxiety, guilt following sexual encounters) 4) Cultural/religious factors (e.g., inhibitions related to prohibitions against sexual activity) 5) Medical factors relevant to prognosis, course, or treatment (Abnormal hormone levels, abnormal levels of brain chemicals called neurotransmitters, inflammation and infection of the prostate or urethra, inherited traits)

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There are a number of potential treatment options for Premature Ejaculation. These include Cognitive Behavioral Therapy, Medications (antidepressants and topical anesthetic creams). The most common treatment, however, is known as The Squeeze Technique (Mayo Clinic, n.d.):

1. The couple begins sexual activity as usual, including stimulation of the penis, until the male with early ejaculation feels the urge to ejaculate. 2. Partner squeezes the end of his penis, at the point where the head joins the shaft, and maintain the squeeze for several seconds, until the urge to ejaculate passes. 3. After the squeeze is released, the couple is instructed to wait for about 30 seconds, then go back to foreplay. 4. Repeat the squeeze process.

By repeating this process as necessary, the male can generally engage in sexual intercourse without ejaculating prematurely. After a few practice sessions, the problem generally remits.

Delayed Ejaculation

Male orgasmic disorder involves persistent or recurrent inability to achieve orgasm despite lengthy sexual contact or while participating in partnered sexual activity in which there is adequate sexual stimulation and the desire to ejaculate. The affected man may regularly experience delays in ejaculation, or may be unable to experience ejaculation altogether. As with Early Ejaculation, Male Orgasmic Disorder may be lifelong/acquired or generalized/situational; there is also a severity criterion. There are no specific time requirements for ejaculation to be considered delayed, and the general rule of thumb is that it is “unacceptably long” for most men and their sexual partners.

Male orgasmic disorder is found in all races and ethnic groups. The lifelong type of the disorder begins with early sexual experiences (generally around puberty) and continues throughout the lifespan. In the acquired type of male orgasmic disorder, the person will have had the previous experience of normal sexual function. In these cases, a situational factor generally precipitates the disorder (causes will be discussed below). This is a less common sexual complaint than some of the others. Only about 75% of men report experiencing ejaculation; less than 1% of men cite ongoing (at least 6 months duration) problems with ejaculation (APA, 2013). Additionally delayed ejaculation increases significantly with normal aging, with men in their 80s reporting twice as much difficulty ejaculating as men younger than 59 years. Some men may report avoiding sexual activity because of sexual dysfunctions.

Male Orgasm

To better define male orgasmic disorder, it is important to review male orgasm. Alwaal, Breyer & Lue (2015) note that orgasm and ejaculation are two separate physiological

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143 processes that are often difficult to distinguish. Orgasm is an intense transient peak sensation of intense pleasure creating an altered state of consciousness associated with reported physical changes.

Orgasm in the male includes emission followed by ejaculation, which is influenced by intricate neurological and hormonal pathways (Alwaal, Breyer & Lue, 2015). Emission refers to a sensation of approaching ejaculation produced by contractions of the prostate gland, seminal vesicles, and urethra. This is accompanied by muscular tension, perineal contractions, and pelvic thrusting. Following orgasm, there is a period of resolution characterized by feelings of well-being and muscular relaxation.

Causes of Delayed Ejaculation

The cause of male orgasmic disorders may be organic or psychological.

Organic causes:

• Use of antidepressant medications, especially SSRIs, • Substance abuse (opioid drug use) • Thyroid disorders (both hyperthyroidism and hypothyroidism) • Pituitary conditions (such as Cushing's syndrome) • Diabetes • Hypogonadism, in which the testes do not produce enough testosterone. • Diseases that affect the nervous system, such as strokes, multiple sclerosis, diabetic neuropathy and spinal cord injuries • Surgery affecting the prostate and other pelvic organs • Process of aging

Psychological causes: • Depression • Feelings of guilt, anger, fear, low self-esteem, and anxiety • Fear of getting partner pregnant or of contracting a sexually transmitted disease • Severe stress • Unsatisfactory relationship with sexual partner • Paraphilic arousal patterns • Past history of sexual trauma • Having been raised in atmosphere of strict sexual taboos • Cultural factors

Treatment

The most common cases of male orgasmic disorder are related to use of SSRIs. The course of action here is to try another medication or to try another medication as an antidote to the SSRI.

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For male orgasmic disorder that is unrelated to SSRIs, standard treatment for inhibited orgasm involves eliminating performance anxiety and ensuring adequate levels of physical stimulation. Similar to the squeeze technique, the couple is instructed to caress the penis manually or orally until erection is attained, but told to cease stimulation when arousal approaches the point of orgasm. This reduces performance anxiety and allows the man to enjoy the sexual pleasure provided by touching. The eventual goal is to allow the man to reach orgasm.

Female Sexual Response and Orgasm

In order to better understand Female sexual dysfunction, it is helpful to review the physiological process of female orgasm. When a woman is sexually excited, the blood vessels in the pelvic area expand, allowing more blood to flow to the genitals. This is followed by a surge of fluid into the vagina, which provides lubrication before and during intercourse. These events are called the "lubrication-swelling response."

Body tension and blood flow to the pelvic area continue to build as a woman receives more sexual stimulation; this occurs either by direct pressure on the or as pressure on the walls of the vagina and cervix. This tension builds as blood flow increases. When tension is released, pleasurable rhythmic contractions of the uterus and vagina occur; this release is called an "orgasm." The contractions carry blood away from the genital area and back into general circulation.

It is normal for orgasms to vary in intensity, length, and number of contractions from woman to woman, as well as in a single individual from experience to experience. Unlike men, woman can have multiple orgasms in a short period of time. Mature women, who may be more sexually experienced than younger women, may find it easier to have orgasms than adolescents or the sexually inexperienced. In orgasmic disorder, sexual arousal and lubrication occur. Body tension builds, but the woman is unable or has extreme difficulty reaching climax and releasing the tension. This inability can lead to frustration and unfulfilling sexual experiences for both partners.

The most effective form of therapy for female orgasmic disorder is a program of directed masturbation, which is used to maximize familiarity with pleasurable sensations, using erotic materials (videos, books) or vibrators. Many therapists also encourage erotic or nonerotic fantasy.

Female Orgasmic Disorder (Anorgasmia)

Female Orgasmic Disorder is the persistent or recurrent inability of a woman to have an orgasm after adequate sexual arousal and sexual stimulation. Inability to have an orgasm, discontent with the quality of orgasms, and the ability to have orgasms only with one type

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145 of stimulation are common sexual complaints among women. Types of orgasmic dysfunction include (Healthline, n.d.):

• Primary anorgasmia is a condition in which the woman has never had an orgasm. • Secondary anorgasmia is a condition in which the woman has difficulty reaching orgasm, even though she’s had orgasms in the past • Situational anorgasmia is the most common type of orgasmic dysfunction. It occurs when the woman can only orgasm during specific situations, such as during oral sex or masturbation. Women’s rates of orgasm consistency (achieving orgasm) are higher during masturbation than during intercourse • General anorgasmia is a condition in which the woman can’t achieve orgasm under any circumstances, even when they are highly aroused and sexual stimulation is sufficient

Studies have found that about half of all women experience some orgasmic difficulties, but not of all these difficulties are considered Female Orgasmic Disorder. About 50% of women experience orgasm through direct clitoral stimulation but not during intercourse, thus not meeting the criteria for a diagnosis of Female Orgasmic Disorder. About 10% of women never experience an orgasm, regardless of the situation or stimulation. For a diagnosis of female orgasmic disorder, the woman must experience significant distress.

Causes of Female Orgasmic Disorder

There are It can be difficult to determine the underlying cause of orgasmic dysfunction. Women may have difficulty reaching orgasm due to physical, emotional, or psychological factors. Contributing factors might include:

• Relationship issues/interpersonal factors • Age (as with other sexual dysfunctions, this may be connected to normal aging and is more prevalent in older women) • Medical conditions, such as diabetes, pelvic nerve damage, spinal cord injury, multiple sclerosis, vaginal dryness or pain • History of gynecological surgeries, such as a hysterectomy • Medications, particularly selective serotonin reuptake inhibitors (SSRIs) for depression • Cultural or religious beliefs • Embarrassment or shyness, including concerns with body image • Guilt about enjoying sexual activity • History of sexual abuse or a recent sexual trauma • Mental health conditions, such as depression or anxiety • Stress • Poor self-esteem • Relationship issues, such as unresolved conflicts or lack of trust

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Treatment

Treatment of orgasmic dysfunction may involve a number of factors, depending on the underlying problem. If the problem is due to a medical condition, it is important to treat that condition. If it is due to a medication side effect, the woman may be switched to a new medication.

Another option is estrogen hormone therapy. Estrogen can be used to increase sexual desire or the amount of blood flow to the genitals for heightened sensitivity. Estrogen hormone therapy may be administered in pill form, as a patch, or as a gel which is applied to the genitals. Testosterone therapy is another an option. However, the U.S. Food and Drug Administration haven’t approved it for treating orgasmic dysfunction in women.

Some over-the-counter (OTC) products and nutritional supplements may also help. These include arousal oils, such as Zestra, which warm the clitoris and increase stimulation. These oils may be beneficial for use during sexual intercourse and masturbation.

Kegel exercises (contraction of the pelvic floor) may also be used to strengthen vaginal muscles that have been stretched through childbirth. Kegel exercises also help to increased muscle tone, improve orgasmic intensity, correct of orgasmic urine leakage, provide distraction during intercourse and improve awareness of sexual response.

Female Sexual Arousal Disorder (FSAD)

Consider the following cases. What is similar in the cases? Different?

Case Vignette 1 Maria and Jose had been married for 12 years. They had recently started to argue about sexual difficulties in the marriage. Since Maria had started the “change,” she was no longer was easily aroused sexually. Although the couple would attempt to proceed with intercourse, it was uncomfortable, and Maria was increasingly avoiding sexual intimacy. She has started going to bed much earlier than Jose, and it has been a frequent source of conflict between them.

Case Vignette 2 Kelly and her partner Paula have been together for 8 years. In the beginning of the relationship, they were sexually active almost daily. Now Paula has been communicating to Kelly that she is not feeling as sexual as she once did, and the couple has been intimate on a weekly basis.

Female Sexual Arousal Disorder is a characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity. The DSM-5 states that because sexual desire and arousal coexist and are elicited in response to adequate sexual cues, making a diagnosis of female sexual arousal disorder should take into account that difficulties in desire and arousal are often simultaneous.

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Female sexual arousal disorder may involve deficits of subjective arousal, in which women do not feel aroused by any type of sexual genital or nongenital stimulation (eg, kissing, dancing, watching an erotic video, physical stimulation), despite the occurrence of physical genital response (e.g., genital congestion), deficits of genital arousal in which subjective arousal occurs in response to nongenital stimulation (e.g., an erotic video) but not in response to genital stimulation or a combined type. In the combined type subjective arousal in response to any type of sexual stimulation is absent or low, and women report absence of physical genital arousal (ie, they report the need of external lubricants and may state they know that swelling of the clitoris no longer occurs).

In sexual arousal disorder, there may be absent or reduced interest in sexual activity, absent or reduced sexual or erotic thoughts or fantasies, no initiation of sexual activity (or unresponsive to partner’s initiation). It is important to note that a factor that should be considered in this diagnosis is whether there is a desire discrepancy. In couples there may be times when one member of the couple has a higher desire threshold than the other partner. Reduced frequency of sexual intimacy is not in itself sufficient to make this diagnosis. Therefore Case Vignette 2 may need further exploration and does not provide enough details and those provided would likely rule out this diagnosis.

Short-term changes in sexual interest or arousal are common among many women and may be responses to events within the women’s life cycle. Symptoms, then, must persist for at least 6 months to be considered a clinical disorder. Subtypes of female sexual arousal disorder include lifelong/acquired and generalized/ situational. There is also a specifier for severity.

Prevalence statistics for Female Sexual Arousal Disorder vary widely, with some sources reporting a lifetime prevalence of 5-10% of adult females, and some reporting up to 20% of adult females. The presence of Female Sexual Arousal Disorder may lead to decreased relationship satisfaction.

Causes of Female Sexual Arousal Disorder may be either physical or psychological. These include:

Physical causes • Surgical procedures such as a hysterectomy may affect changes in blood flow, which can cause a lack of sensitivity and sexual arousal • Decrease in estrogen levels associated with menopause may make the vagina dry and thin, even causing it to shrink • Age-related reduction of testosterone or vulval dystrophy • Medications such as oral contraceptives, antihypertensives and antidepressants (especially SSRIs), benzodiazepenes • Chronic diseases such as diabetes; vascular disease associated with diabetes • Surgical trauma or nerve damage to the pubic area

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Psychological Causes • Depression, stress • Poor body image • Unsatisfactory relationship with sexual partner (relationship well-being) • Past history of sexual/physical trauma • Having been raised in atmosphere of strict sexual taboos

Diagnosis and Treatment

Treatment of sexual arousal disorder depends on the cause of the problem. If there is a physical cause, treatment would target this directly. For example, if the arousal problems are connected to an agent such as an SSRI, the doctor may substitute another medication that does not have this same side effect. If the cause can be remediated by the addition of estrogen (for example, after menopause), doctors often recommend using estrogen inserted into the vagina as a cream, a tablet, or in a ring (similar to a diaphragm).

Another medication that may help is dehydroepiandrosterone (DHEA). A tablet is inserted into the vagina each night. This drug may increase lubrication, lessen atrophic vaginitis, and improve genital sensitivity and orgasm. However, this drug is still under study (Basson, n.d.).

Treatment also often involves working on increased communication between the couple, making sure the setting is conducive to sexual intimacy and helping the woman with grounding skills to enable her to stay more in the moment. Couples may also be encouraged to experiment with different types of sexual stimuli and with activities other than vaginal intercourse.

Genito-Pelvic Pain/Penetration Disorder (Dyspareunia)

Case Vignette Margret and Tim are a newly married (3 months) couple presenting for a conjoint session. Both are products of strict Catholic upbringings. Both are virgins. Margaret’s relationship with the church is complicated by an experience of molestation by a clergy member when she was 8. She feels that she was able to put this behind her and “move on.” The couple has been struggling with to their inability to consummate the marriage, stating that when they try to do so, Margaret is unable to proceed due to fears and pain when Tim they try to proceed to try intercourse.

Genito-Pelvic Pain/Penetration Disorder refers to a condition in which there are persistent difficulties with vaginal penetration during intercourse, marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts, marked fear or anxiety about pain of vaginal penetration or tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

The term dyspareunia refers to pain experienced during intercourse. It is a general term used to describe all types of sexual pain. Sexual pain may occur upon penetration, during

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149 intercourse, and/or following intercourse. It can exist anywhere in the genital area – the clitoris, labia, or vagina, etc. While the diagnostic criteria for Genito-Pelvic Pain/Penetration Disorder is only applied to women, men can also experience pain during intercourse.

Vaginismus is a condition where there is involuntary tightness of the vagina during attempted intercourse. The tightness is actually caused by involuntary contractions of the pelvic floor muscles surrounding the vagina. In some cases vaginismus is so severe that the woman cannot have intercourse (Reissing et al., 2003/2004). Symptoms include anxiety and pain of vaginal penetration; inability to use a tampon (often noted at a young age); inability to remove a tampon that gets “stuck”; severe pain with penetration; complaints that attempted intercourse is like “hitting a wall”; and an inability to tolerate a gynecological examination (Pacik & Geletta, 2017). Women with vaginismus experience shame and embarrassment (Pacik, 2014).

The prevalence of Genito-Pelvic Pain/Penetration Disorder is unknown. About 15% of women report recurrent pain during intercourse (APA, 2013). Women experiencing pain often report its onset after a history of vaginal infections.

In DSM-5, vaginismus is not considered a distinct clinical condition, but such symptoms are included in the diagnostic criteria for Genito-Pelvic Pain/Penetration Disorder. Some researchers have attempted to distinguish vaginismus from dyspareunia. Lahaie et al. (2015) looked at whether fear could differentiate women with vaginismus from those with dyspareunia. Fifty women with vaginismus, 50 women with dyspareunia, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia and no-pain control groups.

There are a number of possible causes of Genito-Pelvic Pain/Penetration Disorder. These include:

Physical causes • Insufficient lubrication; Age-related changes - Menopause and hormonal changes leading to vaginal dryness • Injury, trauma or irritation. Includes injury from pelvic surgery, episiotomy or a congenital abnormality. • Inflammation, infection or skin disorder • Reactions to birth control products. Allergic reactions to foams, jellies or latex or an improperly fitted diaphragm or cervical cap. • Illnesses. Including endometriosis, pelvic inflammatory disease, uterine fibroids, cystitis, irritable bowel syndrome, hemorrhoids and ovarian cysts. • Infections. An infection of the cervix, uterus or fallopian tubes. • Pain related to childbirth

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As with the case vignette presented at the start of this section, there may also be psychological components.

Psychological causes • Depression, anxiety, stress • Unsatisfactory relationship with sexual partner • Past or present history of sexual trauma • Fear - Fear or anticipation of intercourse pain, fear of not being completely physically healed following pelvic trauma, fear of getting pregnant, concern that a pelvic medical problem may reoccur, etc. • Partner issues

Sometimes there is no identifiable cause (physical or non-physical).

Genito-Pelvic Pain/Penetration Disorder can interfere with relationship satisfaction and compromise the ability to conceive during penile/vaginal intercourse.

Treatment of Genito-Pelvic Pain/Penetration Disorder include the use of vaginal dilators, physical therapy with or without biofeedback, biofeedback, sex and relationship counseling, psychotherapy, cognitive behavioral therapy, therapist-aided exposure and hypnotherapy. A personal lubricant can make sex more comfortable. It is also important to treat underlying physical conditions. For postmenopausal women, dyspareunia is often caused by inadequate lubrication resulting from low estrogen levels, and can be treated with a prescription cream or oral medication. Botox has also been shown to have promise in treating Genito-Pelvic Pain/Penetration Disorders.

Sexual Desire Disorders

Case Vignette Mariah and John presented for couples counseling shortly after their son’s first birthday. John was angry, stating that Mariah had been rejecting him since the baby’s birth. The baby slept in bed with them, and Mariah always had an “excuse” as to why she did not want to be sexually intimate.

Inhibited sexual desire (sexual aversion, sexual apathy or hypoactive sexual desire) is characterized by a low level of sexual interest resulting in a failure to initiate or respond to sexual intimacy. Inhibited sexual desire may be a primary or secondary condition. Inhibited sexual desire may also be specific to the partner, or it may be a general attitude toward any potential partner.

A diagnosis of hypoactive sexual desire disorder refers to a persistent or recurring lack of desire or an absence of sexual fantasies. In hypoactive sexual disorder, sexual performance may be adequate once activity has been initiated. This disorder occurs in approximately 20

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151 percent of the population and is more common in women, though it does affect both men and women.

Sexual aversion disorder refers to a condition in which sexual contact is repulsive. This disorder occurs less frequently than hypoactive sexual desire.

Sexual desire disorders are related to both physical and psychological causes. Many of these causes are similar to other sexual disorders discussed previously and include:

Physical causes

• Physical causes resulting in fatigue, pain, or general feelings of malaise • Some medications, such as antidepressants • Hormonal changes; hormonal changes that occur as a result of cancer-directed therapy, which can affect both male and female sexual health (Zhou, Frederick & Bober, 2017) • Epilepsy, and especially role of anti-epileptic drugs (Yogarajah & Mula, 2017) • Insomnia, which can result in fatigue • Spinal cord injury (Liu et al., 2017)

Psychological causes

• Relationship or communication problems • Relationships lacking in emotional intimacy • Lack of affection between partners • Power struggles • Lack of one-on-one time for partners to be alone together • A very restrictive upbringing concerning sex, or negative or traumatic sexual experiences • Depression or excessive stress • History of childhood sexual abuse and persons

Substance-Induced Sexual Dysfunction

Case Vignette

Mark and Molly are a couple that has been married 5 years. They report a satisfactory sex life in the past, but recently the couple has noted more difficulties. Molly has been finding ways to side step his sexual advances. When questioned about this, she is tearful, stating that she wants to be sexual with Mark, but just does not feel aroused by his advances. She also notes that when she does follow through with sex, using a lubricant, she cannot orgasm. In getting a fuller case history, the therapist notes that Molly has started on an SSRI (Prozac) very close to the time that the difficulties began. The therapist suggests that Molly discuss the sexual

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152 concerns with her psychiatrist, and investigate whether it makes sense to try a different antidepressant.

In substance induced sexual dysfunction, the sexual dysfunction is experienced due to a prescription drug or drug abuse of a substance that a person is taking. The dysfunction is of clinical significance and connected to interpersonal/relational difficulties and significant levels of distress.

Factors that distinguish Substance Induced Sexual Dysfunction from any primary sexual dysfunction are:

• Course of duration of the symptoms is during the time the drug has been taken • Onset of the dysfunction is after the drug has been taken • Dysfunction ceases once the medication or drug abuse has been stopped.

Symptoms depend upon the substance used, but may include:

• Impaired sense psychological arousal, impaired lubrication, erectile dysfunction) • Sexual pain syndromes • Impaired sexual desire • Impaired ability to orgasm (which include inability to ejaculate or prolonged ejaculation)

Different types of sexual dysfunctions can be seen in an individual coexisting with intoxication caused by one or more of the following substances:

• Anxiolytics • Amphetamines • Cocaine • Hypnotics • Opioids • Sedatives

Alcohol use, tobacco, and illicit drug abuse/dependence are all known to be associated with sexual dysfunction (Lau, Kim & Tsui HY). Among chronic heroin and morphine users, for example, a review study noted decreases in sexual intercourse frequency, masturbation, and the quality and frequency of orgasm. These effects occur because opioids increase prolactin levels, which affect both the male and female sexual response.

There are also a number of other agents that can inhibit orgasm, contribute to diminished sexual interest and arousal. These include:

• Antiepileptic Drugs (also prescribed for bipolar disorder) • Amoxapine • Antidepressants

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• Antihypertensive Drugs • Histamine H2 Receptor Antagonists • Neuroleptics • Anabolic Steroids • Fluphenazine • Trazodone

Treatment involves diagnosing the agent that is causing the sexual dysfunction. In the case of illicit drug use, regaining sexual function may be a motivator to change. For prescribed medications, a cost/benefit analysis should be done. In some cases there may be a need to either discontinue or lower the dosage.

Therapies for Sexual Disorders

Any therapeutic intervention for sexual disorders begins with an assessment of what underlies the condition. In the case of a psychological cause, therapy is indicated.

Behavior Therapy

The premise of behavior therapy is that sexual problems are the result of prior learning and that they are maintained by ongoing reinforcements and punishments. A key technique is systematic desensitization in which the client is led through exercises to reduce anxiety.

Master’s and Johnson utilize a behavior therapy approach in many of the interventions they developed. A premise of their work is that anxiety is related to goal-oriented sexual performance. Spectatoring involves a person focusing on him or herself from a third person perspective during sexual activity, rather than focusing on one's sensations and/or sexual partner, can increase performance fears and cause deleterious effects on sexual performance. This may not be a strategy to offer to clients who have a history of dissociation.

Sensate focus exercises are aimed at increasing personal and interpersonal awareness of self and the other’s needs. Each participant is encouraged to focus on his or her own senses rather that to view orgasm as the sole goal of sex.

In the first stage of sensate focus, the couple has two sessions in which they take turns touching each other's body, but with the breasts and genitals off limits. The purpose of the touching is to establish an awareness of sensations by noticing sensations of being touched by their partner. In the next stage of sensate focus, touching is expanded to include the breasts and genitals. Again the emphasis is on awareness of physical sensations and not the expectation of a sexual response. The couple then proceeds to mutual touching, then physical closeness in which the woman rubs the penis against her clitoral region, vulva and vaginal opening. In subsequent sessions, and when the couple is ready, the couple proceeds to intercourse.

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Education is another important component of behavior therapy. Topics include information about normal anatomy, sexual function, normal changes of aging, pregnancy and menopause among others.

Cognitive-Behavioral Therapy

Many sex therapists use a combination of the behavioral techniques pioneered by Masters and Johnson (1970) and cognitive-behavioral therapy. Cognitive behavioral therapy is a therapeutic process that attempts to change feelings and actions by modifying or altering faulty thought patterns or destructive self-verbalizations.”(Goldenberg & Goldenberg, 1991) Cognitive restructuring is particularly appropriate in situations in which negative attitudes towards sexuality contribute to sexual dysfunction.

Couples Therapy

The goal of couple’s therapy is to address interpersonal issues in the relationship. Common interpersonal conflicts include relationship conflicts; extra-marital affairs; current physical, verbal or sexual abuse; sexual libido; desire or practices different from partner; poor sexual communication. In couples therapy, partners focus on resolving relationship issues, resolving conflicts and enhancing the relationship. Communication is also a key aspect of couples counseling. Communication training helps couples learn how to talk to one another, demonstrate empathy, resolve differences with respect for each other's feelings, express anger in a positive way, and demonstrate affection. Couples are also helped to learn to reserve time for activities together.

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