Lecture 7: Sex disorders & Paraphilias: Exhibitionism and Frotteuerism What is normal? Difficulty in defining normal? – Bias in self-reports/clinical impressions Sexual dysfunctions – Disruption to ‘normal’ sexual response cycle Masters and Johnston’s & Kaplan’s model: - Desire phase - Excitement phase - Orgasmic phase - Resolution phase Should be: persistent & recurrent. Cause clinically significant distress. Not due to medical condition/other psychological illness. Present: during masturbation + sexual activity Specifiers used to designate onset: - Lifelong - Acquired - Generalised - Situational Types of disorders – Interest, desire & arousal: Male hypoactive sexual desire disorder, erectile disorder. Female sexual interest/arousal disorder Orgasm: delayed ejaculation, premature, female orgasmic disorder Pain: Genito-pelvic pain/penetration disorder (female) Disorders of interest, desire & arousal – Female sexual interest/Arousal disorder – Diminished, absent, or reduced frequency of at least 3 of the following: - Interest in sexual activity - Sexual/erotic thoughts or fantasies - Initiation of sexual activity & responsiveness to partner’s attempts to inititate - Sexual excitement/pleasure - >75% of sexual encounters - Sexual interest/arousal elicited by any internal or external erotic cues - Genital/nongenital sensations - >75% sexual encounters Male Hypoactive Sexual Desire Disorder – Persistently deficient or absent sexual fantasies & desires, as judged by clinician Considerations – age, general/socio-cultural contexts. Comorbidities: depression, other mental disorders Erectile disorder – At least 75% sexual occasions. Prevalence: High, accompanies ageing Inability to attain or maintain erection for completion of sexual activity, or Marked decrease in erectile rigidity interferes with penetration or pleasure Orgasmic Disorders – Female Orgasmic Disorder – On at least 75% of occasions - Marked delay, infrequency, or absence of orgasm - Markedly reduced intensity of orgasmic sensation Premature Ejaculation – Persistent/recurrent pattern of ejaculation during partnered sexual activity within 1 minute following penetration Prevalence: 20-30% at some time Delayed ejaculation – Marked delay, infrequency, or absence of orgasm on at least 75% of sexual occasions Retrograde ejaculation – fluids travel backwards into bladder rather than forwards Sexual Pain disorder – Genitopelvic pain/penetration disorder – Persistent or recurrent difficulties with at least one of following: - Vaginal intercourse/penetration - Marked vulvovaginal or pelvic pain during vaginal penetration or intercourse attempts - Marked fear or anxiety about pain or penetration - Marked tensing of pelvic floor muscles during attempted vaginal penetration NB: commonly associated with relationship distress High prevalence of other disorders related to pelvic floor Substance/medication induced sexual dysfunction Aetiology of sexual dysfunction – Biological contributions: - Neurological problems: diabetes, kidney disorders, vascular disease - Prescription medication: Antihypertensives (blood pressure changers) - Illicit drugs and alcohol Psychological contributions: - Performance anxiety Social/cultural contributions: views/values/norms or experience of traumatic event (rape) Treatment – Providing basic education about sexual functioning Increasing communication between partners Eliminating psychologically based performance anxiety Medications and physical treatments: antidepressants, Viagra etc Paraphilias – many are comorbid with each other, onset generally adolescence Defined by intense, persistent, & recurrent sexual attraction to unusual objects or sexual activities, lasting at least 6 months Diagnosed only when they cause marked distress or impairment (social, occupationally, or other), or engages non-consenting others Disproportionately men, rare in women May cause untold suffering for self & sometimes others Types – - Fetishistic - Transvestic – fantasies, urges, or beh’s involving cross-dressing. Sexual excitement=key - Voyeuristic – watching unsuspecting others undress/have sex - Exhibitionistic – exposing genitals to an unwilling stranger - Frotteuristic – sexual touching of an unsuspecting person - Pedophilic - Sexual sadism – inflicting pain - Sexual masochism – receiving pain Fetishistic Disorder – Fantasies, urges, or behaviours involving the use of nonliving objects or nongenital parts of body: causes sig. distress/impairment. Objects not limited to articles of female clothing etc Onset: adolescence Voyeuristic – Fantasies, urges, or behaviours involving the observation of unsuspecting others who are naked, disrobing, or engaging in sexual activity. Person has acted on these urges with a nonconsenting person or the urges or fantasies cause marked distress or interpersonal problems. Onset: adolescence Sometimes essential for arousal Exhibitionistic – Fantasies, urges or beh’s involving showing one’s genitals to an unsuspecting stranger Seldom attempt to actually contact stranger Triggered by anxiety & restlessness as well as sexual arousal Onset: adolescence Most cases desire to shock or embarrass Often remorseful Frotteuristic – Fantasies, urges, or beh’s involving touching or rubbing against an unconsenting person Person has acted on urges with non-consenting person, or urges/fantasies cause clinically significant distress or problems Onset: adolescence Pedophilic – Fantasies, urges, or behaviours involving sexual activity with a prepubescent child. Arousal is as strong or stronger for children than for adults - Person has acted on urges or urges cause clinically significant distress (CSD) - Person is at least age 16yo and 5 years older than the child Prevalence: victims – up 2.5% of males & 13.5% of females 90% of abusers are male. Typically involve children they know Most not violent outside of sexual act: children rarely forced/injured Not all aggressive offenders have pedophilic arousal patterns (ie assault) Any male can become aroused by erotic pictures of children - Distinction = acting on sexual urges or marked distress Effects on victim – ~1/2 children exposed to childhood sexual abuse (CSA) develop symptoms: depression, low SE, anxiety disorders History of CSA common among adults with mental disorders Increased likelihood of developing a disorder if: perpetrator threatens child, child blames self, unsupportive family, earlier age, involves intercourse BUT: families in which abuse occurs often experiencing other problems Sexual Sadism – Physical or psychological suffering of another person Causes CSD, impairment in functioning, or has acted on urges with non-consenting person Sexual Masochism – Being humiliated, beaten, bound, or made to suffer Causes CSD or impairment in functioning Specify with or without asphixiophilia: oxygen deprivation Typically begins in early childhood: 20-30% Aetiology of Paraphilias – Biological - Excess level of male hormones? - Temporal lobe change? Psychological - Disordered relationships during childhood/adolescence - Physical/sexual abuse - Operant conditioning - OCD – similar paradoxical increase in frequency & intensity - Cognitive distortions Treatment of paraphilias – Focus on engaging client… often difficult to do – lack of motivation to do so CBT: aversion therapy. Biological - Castration - Medications: hormonal to reduce androgens, antidepressants Gender dysphoria – Marked incongruence between one’s experienced/expressed gender and assigned gender Physical gender inconsistent with sense of identity, no physical abnormalities. In children: - Desire to be or insistence that he or she is, the opposite gender - Preference for wearing opposite gender clothing - Preference for cross-gender roles in play or fantasy play - Preference for playmates of the opposite gender - Rejection of toys of assigned gender, dislike of own anatomy, etc In adolescence: - As above – desire to be rid of sex characteristics - Desire to be treated as other gender… conviction of having feelings/reactions of same 1 in 24 000 males, 1 in 150 000 Aetiology – Genetic/neurobiological: Longer CAG repeats on androgen receptor gene for male-to-female GD. CYP17 gene linked to female-to-male GD. Size of bed nucleus of the stria terminalis consistent with ‘identified’ gender Psychosocial factors: reinforcement of X-gender beh. received little support Treatment – Most common: change body to suit gender. High satisfaction: >75% no regrets. .