sign in sign up
<<
Home , Emotional intimacy, Fear of intimacy

4/12/2018

Sex, Intimacy & Psychotherapy: Intimacy in Long Term Relationships Across Gender and Sexual Orientation

Lisa Firestone Ph.D. Michi Fu Ph.D. Lori A. Futterman R.N.,Ph.D. Lisa Firestone Ph.D. Doug Haldeman Ph.D.

Questions to Consider The Experience: Alive Sexuality • Can sexual be maintained over time in long term relationships? Robert W. Firestone, Ph.D. • What causes desire and intimacy to decline in couples over time? Sex is one of the strongest motivating forces in life. It has the potential for creating intense and fulfillment or for causing considerable and • Can one age and remain sexual throughout their life span? . The effect of a natural expression of sexuality on one’s sense of well- • How do our earliest relationships impact our later sexual being and overall enjoyment of life cannot be over-emphasized. The way people relationships? feel about themselves as men and women, their about their bodies, and • What can we as clinicians do to help our clients maintain and even their attitudes toward sex contribute more to a sense of self and of intensify their sexual desire and sexual satisfaction throughout their than any other area of experience. lives? A “healthy” orientation toward sexuality is reflected in a person’s appearance and attractiveness, in the ability to be tender and generous to others, in a sensitivity to children, and in one’s level of overall vitality. The combination of loving, sexual contact and genuine in a stable, long-term relationship is conductive to good mental health and is a highly regarded ideal for most people.

1 4/12/2018

Separation Theory Definition of the Fantasy Bond

Robert W. Firestone, Ph.D. Integrates psychoanalytic and existential systems of Core Conflict: A “fantasy bond” describes an illusion of connection between a Two kinds of couple that is substituted for feelings of real and intimacy. emotional pain: Forming a fantasy bond is an often unconscious act of self- UNDEFENDED DEFENDED parenting and self-protection, in which two people become pseudo-independent, replacing the real relating involved in being in love with the form of being a “couple.” The degree of reliance on a fantasy bond is proportional to the degree of and pain experienced in a person’s developmental years.

INTERPERSONAL EXISTENTIAL FANTASY BOND CRITICAL INNER VOICE

From the Fantasy Bond Couple Interactions Chart

Interactions in an Interactions in a Relationship “Most people have a of intimacy and at Ideal Relationship Characterized by a Fantasy Bond the same time are terrified of being alone. Nondefensiveness and openness. Angry reactions to feedback. Their solution is to form a fantasy bond – an Closed to new experiences. illusion of connection and closeness – that Honesty and integrity Deception and duplicity allows them to maintain emotional distance Respect for the other’s boundaries, Overstepping boundaries. Other seen while assuaging and, in the process, priorities and goals, separate only in relation to self. from self. meeting society’s expectations regarding Physical and Lack of affection; inadequate or and .” personal sexuality. impersonal, routine sexuality. Understanding--lack of distortion Misunderstanding--distortion of the other. of the other.

Noncontrolling, nonmanipulative, Manipulations of dominance and nonthreatening. and submission.

2 4/12/2018

Definition of Voice Processes Definition of the Voice Process

Voice Process: The critical inner voice refers to a well-integrated pattern of destructive toward our selves and others. The “voices” that make up this internalized dialogue are The critical inner voice is like an enemy at the root of much of our maladaptive behavior. This internal enemy fosters inwardness, , self-criticism, self-denial, addictions and a retreat from goal- coach inside your head that encourages directed activities. The critical inner voice effects every aspect of our lives: our self- esteem and , and most importantly, our personal and intimate relationships. you to do everything wrong in your relationship.

Voices about Relationships:  Relationships never work out.  People always just wind up getting hurt.

Couple Relationships Adult Attachment Styles: Regions in a 2-Dimensional Space Romantic love (couple pair-bonding) can be conceptualized as the integration of 3 HIGH AVOIDANCE behavioral systems discussed by Bowlby: attachment, caregiving, and sex

DISMISSING AVOIDANT FEARFUL AVOIDANT

Pair bonding HIGH

LOW ANXIETY

SECURE PREOCCUPIED Hazan and Shaver (1987); Shaver

Attachment et al. (1988) LOW AVOIDANCE From: “Secure and Insecure Love: An Attachment Perspective” Phillip R. Shaver, Ph.D. From: “Secure and Insecure Love: An Attachment Perspective” Phillip R. Shaver, Ph.D. Adapted from Ainsworth et al. (1978), Bartholomew & Horowitz (1991), Fraley & Shaver (2000)

3 4/12/2018

A daily diary study of sexual fantasies… Is your attachment style affecting your relationship?

• Young Israeli couples kept daily diaries concerning sexual fantasies and described aspects of their relationship Secure Attachment: Securely-attached adults tend to functioning for 21 days. be more satisfied in their relationships. • Avoidant attachment was related to sexual fantasies that emphasized non-intimacy, control of sexual interactions, Anxious-Preoccupied Attachment: People with an and negative views of fantasy sexual partners. anxious attachment tend to be desperate to form a • Anxious attachment was related to sexual fantasies that emphasized for closeness, perception of the self fantasy bond. Instead of feeling real love or as weak and dependent, and perception of fantasy toward their partner, they often feel emotional sexual partners as cruel and abusive. hunger.

Source: Birnbaum, Mikulincer, & Gillath, PSPB, 2011

Is your attachment style affecting your relationship?

Dismissive-Avoidant Attachment: People with a dismissive-avoidant attachment have the tendency to emotionally distance themselves from their partner. They’re often the other half of a Fantasy Bond. Fearful-Avoidant Attachment: People with a fearful- avoidant attachment live in an ambivalent state, in Case Presentation which they are afraid of being both too close to or too distant from others.

4 4/12/2018

Case Presentation Questions to Consider • Nancy and Brad (he is 80, she is 78) – met 12 years ago, both had previous (she had 1, he had 2) and numerous other romantic relationships. 1. Do you think Brad and Nancy’s sexual issues may have been • Their presenting complaint according to her was loss of , loss of frequency in sexual impacted by their early relationship with their ? contact. He was more focused on wanting more affection, , and shared time together. • She complains “he looks so old”, is physically insensitive, hurt her feelings long ago, by asking 2. Do you think Nancy and Brad are experiencing critical inner her to cover up and his lack of interest in being oral with her. At times when they are being sexual she sees him as her and feels very disturbed by this thought. She secretly desires voices that are interfering with their sexual relationship? younger men. • He says she comes to bed late and immediately turns on the TV. He also complains that she is 3. Are existential issues contributing to their sexual problems not affectionate, and is often critical towards him. He is critical of himself of struggling to get erections even with viagra and should they be addressed? • Both describe this as the “best relationship they have had”. Her previous relationships have been more sexual, but her partners, including her ex-, have been unstable and sleazy 4. Do Nancy and Brad have a Fantasy Bond and if so, how could financially, much like her father. She has always been a successful bread winner, running her own business. He has tended to idealize women as he did beginning with his . His ex- they get back to relating more lovingly? cheated on him and were controlling, and these marriages were low-sex. He had past affairs, but not in this relationship where honesty is a must for her. He has been medically evaluated for his ED and lack of sexual desire.

Behavioral Checklist for Partners

Describe yourself and your partner along these dimensions on a scale of 1 to 5: 1. Does not describe me/does not describe partner at this time. 2. Describes me on infrequent occasions/describes partner on infrequent occasions. 3. Describes how I am some of the time/describes how my partner is some of the time. 4. Describes how I frequently am/describes how my partner frequently is. 5. Describes me most or all of the time/describes my partner most or all of the time. non-defensive and open (able to listen to feedback without overreacting/open to new experiences): Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 respect for other’s boundaries: Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 vulnerable (willing to feel sad, acknowledge hurt feelings, etc.): Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 honest (straightforward, non-deceptive): Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 physically affectionate: Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 sexuality (satisfied with sexual relationship): Assessment Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 empathic and understanding (lack of distortion of the other): Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 (sense of shared meaning, feel understood): Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 non-controlling, non-manipulative, and non-threatening: Self: 1 2 3 4 5 / Partner: 1 2 3 4 5 How would you rate yourself along these dimensions? sense of well-being: 1 2 3 4 5 self-confidence: 1 2 3 4 5 : 1 2 3 4 5 © The Glendon Association 1999

5 4/12/2018

Experiences in Close Relationships Inventory Psychological, Relational, and Sexual History Format The following statements concern how you feel in romantic relationships. We are interested in how you generally experience relationships, not just in what is happening in a current relationship. Respond to each statement by indicating how much you agree or disagree with it. Write the number in the space provided, using the following rating scale: 1. Conducted individually, not together. Barry W. McCarthy, Ph.D. 1 2 3 4 5 6 7 Disagree Strongly ……… ……… Neutral/Mixed ………. ………. Agree Strongly 2. Start by saying, “I want to understand your psychological, relational, and sexual history both before this marriage and during the marriage… _____ I’m afraid that I will lose my partner’s love. _____ It’s not difficult for me to get close to my partner. _____ I prefer not to show a partner how I feel deep down. _____ I rarely about my partner leaving me. 3. Guidelines: Structure chronologically, move from less anxious to more _____ I often worry that my partner will not want to stay with _____ It helps to turn to my romantic partner in times of need. me. _____ My romantic partner makes me myself. anxiety-provoking questions, be non-judgmental about secrets and non- _____ I feel comfortable sharing my private thoughts and _____ I tell my partner just about everything. socially desirable behavior, ask open-ended questions, probe for trauma and feelings with my partner. _____ I do not often worry about being abandoned. _____ I often worry that my partner doesn’t really love me. _____ I talk things over with my partner. dysfunctional attitudes, behavior, and emotional reactions. _____ I find it difficult to allow myself to depend on romantic _____ I find that my partner(s) don’t want to get as close as I partners. would like. 4. Initial open-ended question—“What did you value about your growing _____ I worry that romantic partners won’t care about me as _____ I am nervous when partners get too close to me. much as I care about them. _____ Sometimes romantic partners change their feelings about up and what caused you problems and ?” _____ I don’t feel comfortable opening up to romantic partners. me for no apparent reason. _____ I often wish that my partner’s feelings for me were as _____ I feel comfortable depending on romantic partners. 5. Social and sexual experiences as a child strong as my feelings for him or her. _____ My desire to be very close sometimes scares people 6. Puberty and adolescence _____ I prefer not to be too close to romantic partners. away. _____ I worry a lot about my relationships. _____ I find it easy to depend on romantic partners. 7. Adult development _____ I get uncomfortable when a romantic partner wants to _____ I’m afraid that once a romantic partner gets to know me, he be very close. or she won’t like who I really am. 8. Present relationship _____ When my partner is out of sight, I worry that he or she _____ It’s easy for me to be affectionate with my partner. might become interested in someone else. _____ It makes me mad that I don’t get the affection and support I 9. Wrap-up questions _____ I find it relatively easy to get close to my partner. need from my partner. _____ When I show my feelings for romantic partners, I’m _____ My partner really understands me and my needs. afraid they will not feel the same about me. _____ I worry that I won’t measure up to other people. McCarthy, Barry, Bodnar, L. Beth, & Handal, Mitsouk (2004). Integrating Sex Therapy and Couple Therapy. _____ My partner only seems to notice me when I’m angry. In Harvey, J., Wenzel, A., & Sprecher, S. The Handbook of Sexuality in Close Relationships. Pp. 573-593. Erlbaum Publishers.

The Therapeutic Process in Voice Therapy with Couples Step I: Each Partner identifies the content of his or her negative thought process and releases the associated . Step II: Each partner discusses insights and reactions to verbalizing the voice and attempts to understand the relationship between voice attacks and early life experience. Step II: Each partner answers back to the voice attacks, which is often a cathartic experience. Afterwards, it is important for each individual to make a rational statement about how he/she really is, how the other person really is, and what is true about the relationship. Step IV: Each partner develops insight about how the voice attacks are influencing his or her behaviors in the relationship. Treatment Step V: Partners collaborate with the therapist to plan changes in these behaviors. The couple is encourages to not engage in aversive behaviors dictated by the voice and to increase the positive behaviors that the voice discourages. Step VI: In dealing with sexual problems, couple learn to give away their “voices” and maintain personal communication in the intervals between formal sessions. They are encouraged to maintain physical contact while “giving away” their self-critical thoughts and hostile attitudes toward each other. This technique often leads to the of deep feelings from the past that can be worked through in subsequent sessions.

6 4/12/2018

Exercise Core Strategies Conclusions

• Adult sexuality is often influenced both by the attachments we Strategies to facilitate sexual desire form as children and how our parents felt about themselves as include: sexual people, as well as how they relate to us and our bodies. • When long-term relationship partners form a Fantasy Bond, the real loving actions between them dissipate, form replaces 1. Nurturing substance and the sexual relationship suffers. 2. Owning your sexuality • Critical inner voices, criticizing ourselves, and our partners often interfere with sexual relating. Criticisms of our bodies and 3. Feeling that you deserve sexual pleasure performance, and of our partners bodies and performance have a destructive effect on our sexual relating. 4. Enjoying arousing, orgasmic sex • Helping couples recognize and break Fantasy Bonds, and challenge critical inner voices can help them greatly improve 5. Valuing intimate sexuality their sexual relationships.

Cultural Aspects of Sexuality & Intimacy

Lisa Firestone, Ph.D. [email protected] www.glendon.org | www.PsychAlive.org Michi Fu, Ph.D. (805) 681-0415

7 4/12/2018

Agenda Questions to Consider

• Questions to ponder • What contributions might culture play in • DESTINIES sexuality? • How might culture influence intimacy? Ethnic Parenting, Youth & Sexuality • • Are there any examples from clinicians of how • Case presentation culture impacts sexuality and intimacy? • Questions/Answers • Are youth influenced by culture as much as their more traditional parents might be?

Culture Counts Youth & Adolescents • Asian American parental communication is a key factor in influencing risk-taking • There has been an increase in youth’s risky sexual activity over recent years (Centers for Disease Control and behavior. Prevention, 2000). • Cultural, environmental and demographic factors, including gender, influence the sexual practice of ethnic • Asian Americans were less sexually experienced and had sexual debut later than minority youth. other groups but were often less sexually knowledgeable. • Living arrangements and other environmental and demographic factors may play major roles in shaping a • For Latinos, ethnic is a protective factor for intentions to have sex, in addition teenager’s sexual behavior and contraception use. to various religious beliefs and attitudes. • Minority adolescents are more likely to be contraceptive non-users, poor users, or users of less effective methods, and unaware of alternative contraceptive methods. • Latina female adolescents had significantly more liberal attitudes towards pregnancy and more conservative attitudes toward birth control than Caucasian • Ethnic minority adolescents are engaging in unprotected much earlier in life. teens. • One in five adolescents have had sex before fifteen years old, and they are more likely to have more sexual partners, use drugs/alcohol, and are at a high risk of being infected with STDs. • African Americans had the earliest sexual debut among Latino and Asian ethnic • On average, youth are having their sexual debut between the ages of 11 and 14. groups. • Youth are at a much higher risk for engaging in risky sexual behavior because they are less likely than older • Finer and Zolna (2011) reported that black women from low income households adults to use contraceptives (Hofferth, 1990). had the highest rates of unintended pregnancies. • Research demonstrated that the more aware racial/ethnic minority youth are regarding contraception, the • For African American females, hip hop music videos in the media have become the lower incidences of risky sexual behaviors. (Ryan, 2007). most influential source of sexuality information. • Ethnic minority youths who feel that they have the information and skills to use condoms are more likely to use them consistently. • African American female youth with less effective problem solving skills and fewer • Unfortunately, sex education is not offered until high school which research has shown is after the initiation of health-promoting behaviors are at risk for initiation of early sex. sexual behaviors and is then less effective.

8 4/12/2018

Ethnic Parenting Parenting Communication

• Research demonstrates that parenting differences between racial groups exist. • There appears to be a difference in parental communication among ethnicities with maternal demandingness predicting increased likelihood of condom use in African American adolescents • Much of the literature has focused on mainstream parenting styles and communication, whereas this same characteristic appears to decrease condom use in White adolescents (Cox, with the exclusion of ethnic differences in parenting styles and communication. 2006). • Racial/ethnic differences in parenting styles and communication have been frequently • -adolescent communication about risks and prevention before sexual initiation was found overlooked by mental health professionals. to be associated with condom use at first intercourse and late discussion was associated with • In certain cultures, parents are more traditional and authoritarian than others (Akinsola, younger age at first intercourse (Atienzo, E., Walker, D., Campero, L., Lamadrid-Figueroa, H., & 2010). Gutierrez, J., 2009). • Mexican American parents were more authoritarian than Mexican and Caucasian • Discussion about risk and prevention prior to sexual initiation was associated with less risk factor. Non-Hispanics (Varela et al.,2004) • Late discussion was associated with more risky behavior. • Culture may affect how parents communicate with their children (Rodriguez, McKay, and • Mothers and do not discuss the same sexual matters with their children. Bannon (2008). • More open and receptive mother-adolescent communication about sex was related to lower. • Parents have reported talking to their youth about sex, but various interpretations of those levels of sexual risk taking among adolescents. “sex talks” were generated. Usually the content of sex talks refers to condom use and birth • Parent’s willingness and ability to discuss sexuality openly and portray it in a positive light control but often do not account for the emotional, ethical, pleasurable and consequential throughout their children’s lives appear to impart both competence and confidence. effects of having sex. • More than the frequency of sex in the family, the content and format of communication also influence adolescents’ contraceptive use.

Ethnic Minorities & Contraception Teaching Our Youth Type of Sex Education Materials Likely Covered Efficacy Strengths Weaknesses • Ethnic minority adolescents’ behaviors vary by race/ethnicity. Deardorf, Virginity Pledges: • Heteronormative Focus • Abstinence • Decreased number of sex • Decreased birth commitments made by teenagers and • Focus Emphasized partners control use at first Tschann, and Flores (2008) found in a sample of Latino youths that there are young adults to refrain from sexual • Moral Values • Delay Sexual Debut sex intercourse until marriage. • Religion • Failure Rate Focus • Less likely to be certain sexual values, such as level of comfort with sexual communication as tested for STI’s Abstinence-Only until Marriage: • Heteronormative Focus • Abstinence • Increased birth control use at • Increase in teen well as self- that can influence contraceptive use. An example of a a form of sex education that teaches • Monogamy Focus Emphasized first sex (males only) pregnancy not having sex outside of marriage. • Moral Values • Delay Sexual Debut • Decreases sexual activity • Decreased sexual value that can play important role in contraceptive use would be level of • Religion • Failure Rate Focus • Evidence for long-term contraceptive use consistency (females) sexual comfort. • Evidence against long-term • Ethnic minorities may be less likely to use contraceptives due to cultural consistency Abstinence-Plus Protection: • Contraception • Delay Sexual Debut • Increased birth control use at • None found beliefs. For example, Hispanic female adolescents were found to be more programs that encourage sexual • Teen Pregnancy • HIV first sex abstinence as the most effective means • STI • Decrease in teen pregnancy of STI and pregnancy prevention, but • Abstinence Emphasized • Increased contraceptive use permissible towards teenage pregnancy (Bersamin, 2002). also teach condom use and partner • Decreased STI Rates reduction. • Decrease in HIV Risk • Evidence for long-term • Hispanic female adolescents were found to be more likely to believe that their consistency parents would not approve of them using contraceptives compared to • Improves overall well-being their Caucasian teen counterparts (Bersamin, 2002). Comprehensive Sex Education: • Contraception • Delay Sexual Debut • Increased birth control use at • None found age-appropriate, medically- accurate • Teen Pregnancy • Abstinence first sex information on topics related to • Sexual Identity Emphasized • Decreased teen pregnancy • When compared to non-Latina participants, Latina participants reported lower sexuality including human • STI • HIV • Decreased sexual activity development, relationships, decision • Abortion • Decreased number of sex levels of contraceptive use. This ethnic difference was partially explained by making, abstinence, contraception, and partners disease prevention. • Increased contraceptive use the level of comfort in communicating about sex and perceived convenience of • Decreased STI rates • Evidence for long-term contraception (Christman & Zawacki, 2009). consistency

9 4/12/2018

Culturally Responsive Discussion w/ Partners

• genogram to understand influence of familial/societal values • Sexual histories (to be taken together or separately?) • Creating groundrules while considering unspoken dynamics • Consider setting and background of relationship (e.g., arranged marriage) Case Presentation • Modifying culturally accepted practices of “assertive communication” • Incorporating indirect methods of communication • Role play

Case Presentation: Case Presentation: Am I Allowed to Have Lovers? Am I Allowed to Have Lovers - Revisited

• 36 year old 1.5 generation Cambodian cis gender female (Elena) Through therapy, Elena was shocked to discover that Stephen is rd • married to 38 year old 3 generation Japanese American cis gender able to maintain erections and sometimes masturbates. male (Stephen). • The couple do not discuss their sexuality with one another outside • The couple ceased to have sexual intercourse shortly after their 5 year of sessions. old son was born, making her feel unattractive and wondering if she is During one session, she shared that she feels repulsive being allowed to have her sexual needs met outside of the marriage. • rejected by her partner while he expressed that she • More recently, they stopped hugging, holding hands and kissing except when forced by their son to hug as a family. tended to be controlling during intercourse with too many rules. • “Elena” has begun to fall asleep while coaxing their son to sleep in his • The two profess that they love one another and but are reluctant to bedroom, which means that they rarely sleep in the same bed. engage in sensate focus as he believes her goals are “moving • Upon intake, she expressed sexual frustration that “Stephen” doesn’t targets.” have the libido that was there when they first married.

10 4/12/2018

Case Presentation: Clinical Implications Who needs school? • Facilitating awareness of different parental styles and practices among mental health professionals is an important step in helping to provide culturally sensitive services to racial/ethnic minority youths and . • 16 year old, 2 nd generation Cambodian American female (“Darling”) • It’s important to design programs that are specifically relevant to racial/ethnic minorities, perhaps by providing a separate curricula that may deemed appropriate for certain cultural groups. referred for academic failure & violence towards others • Physicians, therapists and educators should be accessible as a nonjudgmental source of information for teens. • Darling reported during intake that she’s been sexually active since age • Talking about contraception beforehand and having parents who portray sexuality positively will increase 11 contraceptive use. • Age appropriate but open and honest sex positive conversation should occur in late childhood/early adolescence. • She oftentimes doesn’t use protection and considers herself bisexual • Neighborhoods with a greater concentration of youth who were idle had higher rates of sexual initiation, so after • In order to buy the clothes and make up she wants for herself, she school activities can be used as an intervention. • Educators should focus on increasing ethnic pride of minority students through clubs, multicultural festivals, and in occasionally does import car modeling for extra cash the academic curricula. • Her got upset that she fulfilled his request of having a • Interventions aimed at reducing HIV/STD risk for adolescents need to address patterns of dominance and control in threesome with his “homey” adolescent relationships as well as multiple forms of partner violence, including verbal and emotional . • Virginity pledgers are less likely to know that they had an STD. • She occasionally makes out with one of her and is wondering • Abstinence-only programs are not effective to prevent HIV transmission. if she might be pregnant • Abstinence until marriage programs make no effort to address the unique needs of lesbian, gay, bisexual and transgendered adolescents.

Conclusions References

• Akinsola, E.F. (2010). Correlation between parenting styles and sexual attitudes of young people in Nigeria: Comparison of two ethnic groups. Gender and Behaviour , 8, (1), 2771 - 2788. • Sex education should be offered prior to youths sexual debut, prior to high • Atienzo, E., Walker, D., Campero, L., Lamadrid-Figueroa, H. & Gutierrez, J. (2009). Parent-adolescent school. communication about sex in Morelos, Mexico: Does it impact sexual behavior? The European Journal of Contraception and Reproductive Health Care, 14 (2), 111-119. • Sex talks should incorporate emotional, ethical, pleasurable and • Bersamin, M. (2002). Adolescent contraceptive use: The role of culture on birth control use at first and most consequential effects of having sex. recent sexual intercourse. Dissertation Abstracts International, 62. • Accurate information about the risks of sexual intercourse and the reality of • Christman SK, Zawacki T. Understanding ethnic disparities in Contraceptive Use: The mediating role of attitudes. Under Graduate Research Journal for the Human Science 2009; 8. being an adolescent parent as well as the facts about contraception and • Cox, M. F. (2006). Racial differences in parenting dimensions and adolescent condom use at sexual debut. reproductive health should be provided. Public Health Nursing, 23 (1). • Teach skills through role-play negotiating contraception with multiple types • Deardorff, J., Tschann, J. M., & Flores, E. (2008). Sexual values among Latino youth: Measurement of partners, such as with a partner whom a teen doesn’t know well, an older development using a culturally based approach. Cultural Diversity and Ethnic Minority Psychology, 14(2), 138-146. , or a partner who doesn’t find contraceptive use to be • Finer L.B., Zolna, M.R. (2011). Unintended pregnancy in the United States: Incidence and “romantic”, in addition to saying “no” to unprotected sex. disparities. Contraception , 84(5), 478–85 . • Specific implementation plans should be used as a means to increase • Hofferth, S.L. (1990). Trends in adolescent sexual activity, contraception, and pregnancy in United States. In J. preparatory behaviors. Bancroft & J.M. Reinisch, (Eds.), Adolescence and puberty . New York: Oxford University Press • Rodriquez, J., Cavaleri, M.A., Bannon, W.M., McKay, M.M. (2008). An introduction to parenting and mental health services utilization among African American families: The role of racial socialization. Social Work Mental Health , 6(4), 1-8.

11 4/12/2018

References (cont.)

• American Psychological Association, Task Force on the Sexualization of Girls. (2007). Report of the APA Task Force on the Sexualization of Girls. Washington, DC: American Psychological Association. Retrieved from www.apa.org/pi/wpo/sexualization.html

• Bachanas, P., Morris, M., Lewis-Gess, J., Sarett-Cuasay, E., Flores, A., Sirl, K. & Sawyer, M. (2002). Psychological adjustment, substance use, HIV knowledge, and risky sexual behavior in at-risk minority females: Developmental differences during adolescence. Journal of Pediatric Psychology, 27 (4), 373-384.

• Bersamin, M. (2001). Adolescent contraceptive use: The role of culture on birth control use at first and most recent sexual intercourse.

• Cox, M. (2006). Racial differences in parenting dimensions and adolescent condom use at sexual debut. Public Health Nursing, 23 (1), 2-10.

• Crosby, R.A., DiClemente, R.J., Wingood, G.M., Salazar, L.F., Harrington, K., Davies, S.L., & Oh, M. (2003). Identification of strategies for promoting condom use: A prospective analysis of high-risk African American female teens. Prevention Science , 4(4), 263-270. doi:10.1023/A:1026020332309

• French, C. & Dishion, T. (2003). Predictors of Early Initiation of Sexual Intercourse among high-risk adolescents. The Journal of Early Adolescence, 23 (3), 295-315.

• Kogan, S., Brody, G., Gibbons, F., Murry, V., Cutrona, C., Simons, R., Wingood, G. & DiCLemente,R. (2008). The influence of role status on risky sexual behavior among African Americans during the transition to adulthood. Journal Black Psychology, 34 (3), 399-420. Michi Fu, Ph.D.

• Manlove, J., Ryan, S., & Franzetta, K. (2007). Contraceptive use patterns across teens' sexual relationships: the role of relationships, partners, and sexual histories. Demography, 44, 3, 603-21. • Malott, K. M., Paone, T. R., Humphreys, K., & Martinez, T. (2010). Use of Group Counseling to Address Ethnic Identity Development: Application with Adolescents of Mexican Descent. • [email protected] Professional School Counseling , 13 (5), 257-267. • Reznik, Yana, & Tebb, Kathleen. (n.d.). Where Do Teens Go to Get the 411 on Sexual Health? A Teen Intern in Clinical Research with Teens . The Permanente Journal. • (626) 538-5108 • Roche, K.M., Mekos, D., Alexander, C.S., Astone, N., Bandeen-Roche, K., & Ensminger, M.E. (2005). Parenting influences on early sex initiation among adolescents: How neighborhood matters. Journal of Family Issues , 26 (1), 32-54. • Ryan, S., Franzetta, K., & Manlove, J. (2007). Knowledge, Perceptions, and Motivations for Contraception: Influence on Teens' Contraceptive Consistency. Youth & Society, 39, 2, 182-208. • California & Hawaii • Stephens, D. P., & Phillips, L. (2005). Integrating Black feminist thought into conceptual frameworks of African American adolescent women's sexual scripting processes. Sexualities, Evolution & Gender, 7, 1, 37-55. • https://www.psychologytoday.com/us/therapists/l • Teitelman, A. M., Ratcliffe, S. J., Morales-Aleman, M. M., & Sullivan, C. M. (2008). Sexual relationship power, intimate partner violence, and condom use among minority urban girls. Journal of Interpersonal Violence , 23 (12), 1694-1712. os-angeles-county-monterey-park-ca/73177 • Tenkorang, E., Rajulton, F. & Maticka-Tyndale, E. (2009). Perceived risks of HIV/AIDS and first sexual intercourse among youth in Cape Town, South Africa. AIDS and Behavior, 13 , 234-245.

• Usher-Seriki, K., Smith Bynum, M. & Callands, T. (2008). Mother-daughter communication about sex and sexual intercourse among middle- to upper-class African American girls. Journal of Family Issues, 29 (7), 901-917.

• Van Empelen, P., & Kok, G. (2006). Condom use in steady and casual sexual relationships: Planning, preparation and willingness to take risks among adolescents. Psychology & Health , 21 (2), 165-181. doi:10.1080/14768320500229898

• Youn, G. (2001). Perceptions of peer sexual activities in Korean adolescents. Journal of Sex Research, 38 (4), 352-360.

Questions to Consider

• What is Female Sexual Dysfunction (FSD) and do they differ across Female Sexual Dysfunction sexual orientation and gender? • What contributes to sexual dysfunction? • How do we assess for sexual dysfunction? When do we need to refer to a specialist? • Even though we customize our treatments, what are some ways to treat the sexual dysfunctions? Lori A. Futterman R.N.,Ph.D.

12 4/12/2018

Strides in Sexuality How Does Sexual Functioning Work: Sexual in Western Culture Response Cycle • Sexual functioning is an integral part of health and well-being

Today the emphasis is on quality of our sex lives Orgasm • Sexual Plateau • Science and treatment have advanced from “The Graying of America”, Excitement / “Viagraization of America” and “Sexual Pharmacology” to the field of Tension Sexual Medicine Arousal • Research and treatment is best viewed through the lens of the biopsychosocial model of sexual functioning Resolution • Sex is more openly discussed within our culture except if the problem is Desire more self-focused and one is suffering from a sexual dysfunction Time

Elders et al., 2010; Herbenick et al., 2010; Kingsberg et al., 2017. Masters & Johnson, 1966; Kaplan, 1979.

Sexual Response Cycle: What Do Intimacy and Love Have Intimacy-Based Model To Do With Sexual Functioning?

Emotional • Emotional intimacy and feelings of love enhance and sustain sexual Intimacy satisfaction and pleasure • Types of love and sexual frequency are on a continuum from and Motivates the sexually + neutral woman (increase in sexual responsivity and activity) to friendship and + commitment (reduction in sexual frequency) To find / be • Love may be seen as changes in neurohormones and neuropeptides (e.g., Emotional and Physical “Spontaneous” responsive to Satisfaction oxytocin) that mediate attachment and regulate emotional, cognitive, sexual drive; Sexual Stimuli “hunger” behavioral and biological processes Psychological and biological factors • Studies using neuroimaging techniques (fMRI), help to identify brain govern “arousability” networks involved in attachment and assist in the understanding of the love relationship and its impact on sexual function and dysfunction Arousal and Sexual Desire Sexual Arousal

Basson, 2000. Bartels et al.,2000; Diamond, 2004, Aron et al.,2005; Levine, 2007; Ortique 2010;McCabe et al., 2010.

13 4/12/2018

Categories of Female Sexual Dysfunctions Myths vs. Realties and Sex (DSM-5 ) Regardless of gender identity or sexual orientation FSD appears • That it’s spontaneous and natural There is a limited research on prevalence across LBTQ population • It’s easy, timeless and requires nothing from you Disorders: • What behaviors do we engage in that •Female Hypoactive Desire Disorder and Arousal Disorder — Merged into do not take any strategy or plan? Why Female Sexual Interest/Arousal Disorder should sex be any different? •Persistent Arousal Disorder (not in DSM-5) • The awareness that sex is complicated •Female Orgasmic Disorder : Unchanged but with imagination is fun and exciting •Dyspareunia and Vaginismus — Merged into Genito-Pelvic • Sexual disorders rarely occur alone, co- Pain/Penetration Disorder, includes Pelvic Floor Muscle Dysfunction morbidity of desire, arousal and orgasm is common •Aversion Disorder (not in DSM-5)

Perel, 2015. Ishak, & Tobia, 2013.

Prevalence of Sexual Dysfunction: Current Diagnostic Criteria for FSD Meeting the Criteria 8.9 million adults in USA suffer from a diagnosable sexual dysfunction Distressing Sexual Problems: Age Stratified (PRESIDE) a cross sectional, disorder population-based study: N=31,581 • All disorders must be “persistent or recurrent” Age-stratified Desire Arousal Orgasm Any • All disorders must cause “personal distress” prevalence 2,868/28,447 1,556/28,461 1,315/27,854 3,456/28,403 • Subtypes: • A = Lifelong vs. acquired 18 – 44 years 8.9 3.3 3.4 10.8 • B = Generalized vs. situational • C = Etiologic origin (organic, psychogenic, mixed, unknown 45 – 64 years 12.3 7.5 5.7 14.8 •Duration and frequency • Symptoms need to persist for approx. 6 months 65 years or 7.4 6.0 5.8 8.9 older • Occur on 75-100% of sexual activity •Severity: mild, moderate, severe

Mitchell et al., 2016; et al., 2015. Shifren et al., 2008.

14 4/12/2018

Biopsychosocial Model: Mood Disorders & FSD Contributors to Sexual Functioning & FSD • Sexual dysfunction is reported to be 2-3 times more likely in a depressed population • High correlation between severity of and severity of sexual dysfunction • Anxiety disorders: data is lacking • Bipolar Mood Disorders: data is lacking • Sexual dysfunction following trauma may be mediated by PTSD • Antidepressants interfere with sexual functioning

Rosen et al., 2006; Kingsberg et al., 2017. Angst 1998;Letourneau 1996; Kennedy et al.,1999; Smith et al., 2010; Fabre et al., 2012; Yehuda et al 2015

Sexual Orientation, Gender and Fluidity: Sexual Functioning

• Sexual orientation and gender identity is stable for some and fluid for others • Sexual fluidity is a change over time in sexual orientation and gender identity and maybe influenced by hormonal treatments and gender- confirming surgeries • Research on sexual fluidity has been based on cisgender populations and can not be generalized to transgender, gender non-binary or Assessment transitioning • Shifts in sexual functioning can occur across sexual orientations and gender transitions

Diamond, 2008; Dargle et al., 2014;Katz-Wise, 2014,2015; Diamond et al., 2011; Kuper et al., 2012; Meir et al., 2013; Rosario et al., 2014; Auer, 2014.

15 4/12/2018

Attachment and Differentiation of Self Clarifying the Sexual Problem • Are the symptoms are acquired or lifelong? Generalized or • Attachment avoidance and situational? attachment anxiety associated with FSD • What phases of the sexual response cycle (i.e., desire, arousal, orgasm, resolution) are involved? What is the level of distress? • Lower levels of differentiation of self: strongest predictors of sexual • Does the problem bother the patient or her partner? difficulties • Evaluate the context of the symptom: • Higher levels of psychological  Past and present relationships distress associated with sexual difficulties  Currently active? • Positive mood, positive partner  Partner’s response? behavior and positive relational  Is the problem psychogenic, organic, or a combination? feelings predicted more sexual activity and intimacy

Burri et al., 2014; DeWitte et al, 2015. Maurice & Bowman, 1999; Basson, 2003.

Initial Considerations What a Comprehensive Sexual History Includes

• Medical and gynecological histories, exam, including lab and/or • Is the dysfunction likely a result of “predisposing factors?” hormonal tests Trauma, disturbing family relationships • Sexual history of patient or patient and partner • Is the dysfunction likely a result of a “precipitating factor?”  Attitudes and knowledge the patient has about sex Gender transition, , problems related to childbirth, fertility  What the patient learned about relationships difficulties, ovarian decline, other age-related changes, life-stressors  Current sexual behavior • Is the dysfunction likely a result of “maintenance factors?”  Socio-cultural influences on sexual attitudes and behavior Anticipation of sexual failure, poor communication, inadequate education  History of sexually transmitted diseases  Trauma  Use of contraceptives  History of medication and use of controlled substances

Leiblum et al., 2004.

16 4/12/2018

Questionnaires for Evaluating Factors Associated With Dysparunia Sexual Functioning Outer/Mid-Vaginal Deep Vaginal • Female Sexual Function Index (FSFI) •Inflammatory vulvar vestibulitis •Endometriosis (VVS) • Female Sexual Distress Scale (FSDS), the FSDS-Revised (FSDS-R) •Pelvic inflammatory disease Hormonal • •Referred pain • Personal Sentence Completion Inventory (PSCI) Muscular • •Uterine retroversion • The Multidimensional Vaginal Penetration Disorder Questionnaire •Traumatic •Pelvic varicocele (MVPDQ) Neurological • •Outcome of radiotherapy and • McGill-Melzack Pain Questionnaire (MPQ) •Vascular surgery

Miccio-Fonseca, 1999;Rosen et al., 2000;Quirk et al.,2002; DeRogatis et al., 2002; Ter Kuile et al.,2006;Brandon et al.,2010; Fisher et al., 2010; Meston & Trapnell, 2005; Corcoran et al., Graziottin, 2003; Schultz et al., 2005; Jodoin et al., 2008; Sutton et al., 2008. 2013;Molaeinezhad et al., 2014;Kingsberg et al., 2017.

Factors Associated With Pelvic Floor Muscle Sexual Assault/Trauma and Dysfunction (AKA Vaginismus) Sexual Functioning

• Numerous studies suggest that 13-45% of women will experience • Commonly reported in unconsummated marriages sexual assault during their lifetime • Co-morbidity with anxiety • Staples found: sexual difficulties associated with sexual assault • No reliable data concerning incidence • 59% of assault histories compared to 17.2%(control group) suffered • Suspected if patient complains about trouble with penetration sexual problems • Can originate from: • Prospective study showed 61% experienced some disruption in sexual functioning immediately after and 20% reported sexual problems one  A specific event (e.g., sexual abuse or traumatic pelvic exam) year after.  An underlying psychodynamic conflict • Disclosing experiences of sexual assault could serve to lessen traumatic  A conditioned reaction to recurrent vulvodynia symptoms and decrease the effect on sexual functioning

Leiblum & Rosen, 2000; Schultz et al., 2005; Sidi et al., 2007; Dogan, 2009; Borg et al., 2010. Staples et al., 2016.

17 4/12/2018

Treatment for FSD is Multidimensional: East Meets West

• Individual and/or Couples Psychotherapy: Mindfulness Training Meditation; Clinical Hypnosis Cognitive-Behavioral Psychotherapy CBT Eye Movement Desensitization Reprocessing (EMDR) Treatment • Combined psychotherapy with biomedical interventions produces the optimum outcomes • Hormonal stabilization and medical intervention • Eastern approaches: acupuncture; herbs; yoga

Wernick, 1993; Madrid et al., 2006; Koedam, 2007; Moses, 2007; Brotto et al., 2008; Elton, 2009; Al-Azzawi et al., 2009; Nobre et al., 2010; Basson et al., 2010.; Kingsberg et al 2017.

Psychological Treatment of Case Presentation Sexual Disorders • A 33 year old married Caucasian woman, with some college education presented for psychotherapy with the presenting problem “…had been married to my nesting Hypoactive Desire Orgasmic partner for 9 years; I have never been able to be penetrated.” She describes her •, Mindfulness Training, •Relaxation, Mindfulness Training, relationship as “great”. “This is the first sexual relationship for both of us”. Hypnosis Hypnosis • She has noticed that her desire to engage in any sexual relationship has dropped •Sexual skill building •Orgasmic consistency training and states “ I engage out of obligation”. ‘I just think of the pain I have down there and I don’t want to get too close. When we do get time together I can get aroused •Drive induction •Vibrator and have an orgasm but it takes forever”. Sensate focus • • She reports having “terrible anxiety and attacks” which is focused on “getting Arousal Pain germs” and “cleaning the bathroom over and over again to make sure” that nothing dirty enters me”. •Relaxation, Mindfulness Training, •Relaxation, Mindfulness Training, Hypnosis Hypnosis • She revealed a memory that at age 8. “While playing a game with both of my •Sexual skill building brothers, my oldest brother pulled me in the bathroom and wanted me to look at •Imagery exercises his genitals. I don’t remember anything else”. •Increase genital sensitivity •Systematic desensitization(EMDR) • She is not taking any psychotropic or any oral contraceptive. Hormonal panel •Sensate exchange •Lubricants revealed normal estradiol level and FSH but low testosterone •Vibrator •Vaginal inserts •Eros device

18 4/12/2018

Questions To Consider Conclusions

• Patients rarely present with sexual dysfunction; they usually suffer in silence • What are the clinical issues to be addressed? • Love, intimacy and sexuality are evaluated on a continuum • Would your assessment differ across gender and sexual orientation? • Complexity of sexual functioning gave credibility to the field of sexual medicine • What are the treatment considerations? • Sexual disorders have co-morbidity with complaints of desire, arousal and orgasm • Assessment and treatment need to be comprehensive, and include medical, gynecological, reproductive endocrinologist, and psychological aspects

Male Sexuality

Lori A. Futterman R.N.,Ph.D 591 Camino de la Reina Ste 705 San Diego, Ca. 92104 Douglas C. Haldeman, Ph.D. [email protected] John F. Kennedy University drlorifutterman.com 619-297-3311

19 4/12/2018

Questions to Consider Hegemonic (toxic) Masculinity

• How do men differentiate sex and intimacy? • The sexual world inside a man’s head: fantasy and reality • What factors play a role in male psychogenic sexual • Learned patterns of dominance and competition that do dysfunction? not translate well to sex and intimacy #MeToo • What are the most common male sexual problems, and • Internalized, uncritically accepted (and unrealistic) how are they treated? messages about masculinity and sexuality • How stable/fluid are sexual orientation and gender • Myths derived from masculine socialization identity? • Adversarial relationship with penis • Do heterosexual/cisgender men experience the same kinds of sexual concerns as gay/bi/or trans men?

Hegemonic Masculinity Male Sexual Mythology • Hegemonic masculinity is defined as a practice that legitimizes men's • We are all comfortable with sexual liberation dominant position in society and justifies the subordination of women, and other marginalized ways of being a man. (Connell, 2005) • It is unmanly to discuss feelings (especially ). • In contemporary American and European culture, [hegemonic • Sex is goal-oriented; touching leads to sex and intercourse masculinity] serves as the standard upon which the “real man” is defined. According to [R.W] Connell, contemporary hegemonic • A man is always ready for sex masculinity is built on two legs, domination of women and a hierarchy • Sex is a performance of intermale dominance. It is also shaped to a significant extent by the stigmatization of homosexuality. Hegemonic masculinity is the • Sex is about your hard, durable penis stereotypic notion of masculinity that shapes the socialization and • ED? Viagra fixes everything aspirations of young males. Today’s hegemonic masculinity in the United States of America and Europe includes a high degree of • The earth should move ruthless competition, an inability to express other than , an unwillingness to admit weakness or dependency, • And all of the above without any discussion or planning devaluation of women and all feminine attributes in men, (Zilbergeld, 1999) homophobia, and so forth (Kupers, 2005)

20 4/12/2018

What’s a normal pattern of male sexual arousal? Assessment of Male Sexual Dysfunction • Medical issues • Aging • Medication • Substance use • Life issues: stress and anxiety, relationships, attitudes about sexuality

Psychogenic Male Sexual Dysfunction Developing Ejaculatory Control • Getting inside a man’s head: understanding the narratives that inform sexual arousal and expression • Understanding a man’s conditions for good sex • Expressing himself – and listening • The difference between assertion and aggression in sexual communication • Chronicity of an issue: getting un-stuck in your head; a sex journal

21 4/12/2018

Developing Ejaculatory Control Assessing Erection Problems

• Mindfulness about state of arousal • 52% of men between the ages of 40-70 • Assess use of drugs (prescription and • Stop/start technique; squeeze technique recreational), alcohol, tobacco (Semans, 1956) • Medical assessment: blood pressure, other blood tests, RigiScan test • SSRI medication • Duration and severity of concern • Topical medicines • Apps

Treating Erectile Dysfunction: Advantages and Assessment/Treatment of Low Sexual Desire Disadvantages • Make sure behavioral/substance issues are • Medical issues: medications, low hormone addressed first levels, drugs, depression • Vacuum devices • Partner issues; scheduling, stress; anxiety • ED drugs (Viagra, Cialis) about sex • Prostaglandin injections • Assess scheduling, conditions for sex; partner communication • Penile implants (Nonhydraulic, hydraulic) • Behavioral methods: masturbatory exercises, sensate focus

22 4/12/2018

Assessment/Treatment of Inhibited/Delayed What do we know about sexuality and Ejaculation gender diversity? • More common among gay men than • How fluid is sexual attraction/fantasy? straight/bi • How are sexual orientation and gender • Assess chronicity, situation identity differentiated? • Assess masturbatory patterns • What does “gender neutral” mean in relation • Inventory of medications, medical issues to sexuality? • Masturbation exercises; successive • Are most trans persons gay or lesbian? approximation • What are the sexual concerns of trans • Drugs (Periactin, Symmetrel, Buspar) persons?

Dave

Dave is a 35 year-old bisexually-identified and heterosexually married father of three young children. He and his have been married for 10 years. Dave and his wife identify as evangelical Christians, and attend church regularly. Background: Dave has experienced attractions to both males and females since adolescence, but identifies as heterosexual Case Presentation based on his self-perceived preferences as well as internalized cultural factors. Nonetheless, he has had numerous sexual experiences with other men, but no same-sex relationships.

23 4/12/2018

At issue: Following the birth of the couple’s youngest child three years ago, however, their sexual frequency diminished markedly, Dave grew up in a conservative town in the midwest where he with Dave’s wife evidencing less interest. Subsequently, Dave has learned at an early age that there was something wrong with found himself unable to resist visiting highway rest stops where being a “sissy”. Although aware of his same-sex attractions in he engages in anonymous sexual encounters with other men. He early life, he never disclosed this to anyone. His same-sex limits these activities to oral sex, rationalizing that it is less experiences have been limited to anonymous encounters in intimate, and poses fewer health risks, than anal intercourse. public places. Still, Dave feels guilty and shameful about his behavior. He has never discussed his same-sex attractions or behavior with his When he got married ten years ago, he vowed to himself that he wife for fear that she would leave him if she knew. would discontinue all same-sex activities, and be sexually exclusive with his wife. For several years, the couple maintained Dave says that he still feels attracted to his wife, and wishes to a satisfying sex life and his “same-sex abstinent” strategy was rekindle a sexually fulfilling relationship with her. successful.

At issue: Following the birth of the couple’s youngest child three Finally, Dave reports that over the course of the past year, on years ago, however, their sexual frequency diminished markedly, those occasions when he and his wife have had sex, it has been with Dave’s wife evidencing less interest. Subsequently, Dave has very difficult – and sometimes impossible – for him to ejaculate. found himself unable to resist visiting highway rest stops where Even more frightening to him is that on those occasions when he he engages in anonymous sexual encounters with other men. He has been able to ejaculate, it has been because he was thinking limits these activities to oral sex, rationalizing that it is less about one of his rest stop encounters. intimate, and poses fewer health risks, than anal intercourse. Still, Dave feels guilty and shameful about his behavior. He has never discussed his same-sex attractions or behavior with his Dave understands that it is not realistic to expunge his same-sex wife for fear that she would leave him if she knew. fantasies, but seeks to avoid acting on them. His other treatment goal is to re-establish a positive, fulfilling sexual relationship with his wife. Dave says that he still feels attracted to his wife, and wishes to rekindle a sexually fulfilling relationship with her.

24 4/12/2018

Questions to Consider (cont.)

1. Is it realistic to think that Dave could refrain from 4. How would you address Dave’s delayed his extra-marital same-sex encounters? If so, what ejaculation? would be required? If not, why not? 2. What are the implications of speaking openly with his wife? What are the risks of discussing – and not 5. 5. How might you design treatment for the couple, discussing – his same-sex attractions? assuming that Dave’s wife shares his goal of re- connecting sexually? 3. Were Dave to discuss his history of same-sex attractions, should he also discuss his same-sex behaviors?

Douglas C. Haldeman [email protected] (925) 969-3583

25