Sexual Disorders Aaron J. Blashill, M.S.

Lykins, Janssen & Graham (2006) Do some individuals with depression and/or anxiety experience sexual arousal as opposed to sexual decline? Do some individuals with depression and/or anxiety experience sexual arousal as opposed to sexual decline? In their review, they found that for both depression and anxiety, there was a subset of individuals who experienced sexual arousal (both men and women). In their review, they found that for both depression and anxiety, there was a subset of individuals who experienced sexual arousal (both men and women).

Lykins, Janssen & Graham (2006) Dual control model Dual control model Individuals vary in their propensity for both sexual excitation and inhibition Individuals vary in their propensity for both sexual excitation and inhibition

Lykins, Janssen & Graham (2006) Generally, there were subgroups of both men and women who experienced sexual arousal during a negative mood state. Generally, there were subgroups of both men and women who experienced sexual arousal during a negative mood state. Why might some individuals be sexually aroused when distressed? Why might some individuals be sexually aroused when distressed? For women, the only variable which research significance in prediction was propensity for sexual excitation accounting for 3% of the variance. For women, the only variable which research significance in prediction was propensity for sexual excitation accounting for 3% of the variance. Thoughts? Thoughts?

Clayton, Keller & McGarvey (2005) Examining the prevalence of phase-specific SD in a depressed sample without global SD. Examining the prevalence of phase-specific SD in a depressed sample without global SD. Comparing prevalence rates of SD for each phase (desire, arousal, orgasm) for men and women. Comparing prevalence rates of SD for each phase (desire, arousal, orgasm) for men and women. Comparing prevalence rates of phase-specific SD for different SSRI/SNRIs Comparing prevalence rates of phase-specific SD for different SSRI/SNRIs

Clayton, Keller & McGarvey (2005) SD is a common side effect of SSRI/SNRIs SD is a common side effect of SSRI/SNRIs Rates from 22-43% to 30-60% Rates from 22-43% to 30-60% What might be some possible effects of deleterious side effects? What might be some possible effects of deleterious side effects? In their review, authors found that men experienced more impairment in desire than women, but no difference of arousal or orgasm (when on SSRIs and RIMAs) In their review, authors found that men experienced more impairment in desire than women, but no difference of arousal or orgasm (when on SSRIs and RIMAs)

Clayton, Keller & McGarvey (2005) Evident from clinical practice that phase- specific SD can sig. reduce quality of life even when global SF is not impaired. Evident from clinical practice that phase- specific SD can sig. reduce quality of life even when global SF is not impaired. Results found numerous differences on variables between groups (those with Global SD vs. without) Results found numerous differences on variables between groups (those with Global SD vs. without) Prevalence rates of phase-specific SD without Global SD: desire (82.4%) arousal (80%) orgasmic (56.6%) Prevalence rates of phase-specific SD without Global SD: desire (82.4%) arousal (80%) orgasmic (56.6%)

Clayton, Keller & McGarvey (2005) 80% had SD in more than one phase, but still didn’t met criteria for Global SD. 80% had SD in more than one phase, but still didn’t met criteria for Global SD. Men were sig. more likely to experience SD in the desire and orgasmic phase than women, although vice versa in arousal…Thoughts? Men were sig. more likely to experience SD in the desire and orgasmic phase than women, although vice versa in arousal…Thoughts? No sig. differences between SSRI/SNRIs with regard to phase-specific SD No sig. differences between SSRI/SNRIs with regard to phase-specific SD The negative effects on SF appear to be chronic and interfere with the quality of patients life The negative effects on SF appear to be chronic and interfere with the quality of patients life

Brotto & Klein (2007) Sexual dysfunction Sexual dysfunction Problems in desire, arousal, orgasm, or pain Problems in desire, arousal, orgasm, or pain Based on Masters and Johnson’s Human Sexual Response Cycle (excitement, plateau, orgasm, and resolution) Based on Masters and Johnson’s Human Sexual Response Cycle (excitement, plateau, orgasm, and resolution) Desire was added by Kaplan (1979) Desire was added by Kaplan (1979) Problems with this system… Problems with this system… DSM-IV divides disorders into 6 categories DSM-IV divides disorders into 6 categories

Brotto & Klein (2007) Prevalence rates for sexual difficulties in women 43% men 31% Prevalence rates for sexual difficulties in women 43% men 31% Being married and having a higher level of education was associated with lower degrees of difficulties Being married and having a higher level of education was associated with lower degrees of difficulties

Brotto & Klein (2007) Hypoactive Sexual Desire Disorder Hypoactive Sexual Desire Disorder Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity 15% of men aged % of women aged % of men aged % of women aged Hypothyroidism, cancers, cardio-diseases, psychiatric medications, medical drugs, illicit drugs have effects Hypothyroidism, cancers, cardio-diseases, psychiatric medications, medical drugs, illicit drugs have effects ADAM (andropause…male menopause) ADAM (andropause…male menopause) Fatigue, depression, reduced sex drive, ED, changes in mood and cognition Fatigue, depression, reduced sex drive, ED, changes in mood and cognition

Brotto & Klein (2007) Sexual Aversion Disorder Sexual Aversion Disorder Persistent or recurrent extreme aversion to and avoidance of all (or almost all) genital sexual contact with a sexual partner Persistent or recurrent extreme aversion to and avoidance of all (or almost all) genital sexual contact with a sexual partner May experience panic attacks May experience panic attacks Highly distressing (ego-dystonic) Highly distressing (ego-dystonic)

Brotto & Klein (2007) Male Erectile Disorder Male Erectile Disorder Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection Causes distress Causes distress 7% in men aged 18-29, 18% 50-59, 24% % in men aged 18-29, 18% 50-59, 24% Anxiety or stress may lead to an overactive sympathetic nervous system…leads to loss of erection Anxiety or stress may lead to an overactive sympathetic nervous system…leads to loss of erection Major Depressive Disorder strongly associated with ED Major Depressive Disorder strongly associated with ED

Brotto & Klein (2007) Female Sexual Arousal Disorder Female Sexual Arousal Disorder Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication, swelling response of sexual excitement Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication, swelling response of sexual excitement 12-21% 12-21% Persistent sexual arousal disorder Persistent sexual arousal disorder Spontaneous intrusive and unwanted genital arousal in the absence of sexual interest and desire…often only temporarily relieved by orgasm Spontaneous intrusive and unwanted genital arousal in the absence of sexual interest and desire…often only temporarily relieved by orgasm

Brotto & Klein (2007) Female Orgasmic Disorder Female Orgasmic Disorder Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase 22-25%...highest prevalence in young women 22-25%...highest prevalence in young women A skill that perhaps develops over time A skill that perhaps develops over time Associated with lower education, high religiosity, and sex guilt…no relationship between rel satisfaction and orgasmic ability Associated with lower education, high religiosity, and sex guilt…no relationship between rel satisfaction and orgasmic ability Myth of the “G-spot”? Myth of the “G-spot”?

Brotto & Klein (2007) Male Orgasmic Disorder (retarded ejaculation) Male Orgasmic Disorder (retarded ejaculation) Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity Much less frequent than PE (premature ejaculation) Much less frequent than PE (premature ejaculation) 8% men aged % men aged Idiosyncratic masturbatory style, variant sexual fantasy, predisposing factors…alcohol use related and performance anxiety Idiosyncratic masturbatory style, variant sexual fantasy, predisposing factors…alcohol use related and performance anxiety

Brotto & Klein (2007) Premature Ejaculation Premature Ejaculation Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it 30% of men aged % of men aged Most prevalent male sexual dysfunction Most prevalent male sexual dysfunction Highly embarrassing condition Highly embarrassing condition Serotonergic disruption likely primary etiological factor Serotonergic disruption likely primary etiological factor 71% of first-degree relatives of men with PE also have the condition 71% of first-degree relatives of men with PE also have the condition situational/acquired PE may be more due to anxiety, early sexual experiences, low frequency of sex, or poor ejaculatory control techniques…new studies suggest that anxiety is more of a consequence rather than a cause situational/acquired PE may be more due to anxiety, early sexual experiences, low frequency of sex, or poor ejaculatory control techniques…new studies suggest that anxiety is more of a consequence rather than a cause

Brotto & Klein (2007) Dyspareunia Dyspareunia Recurrent or persistent genital pain associated with sexual intercourse Recurrent or persistent genital pain associated with sexual intercourse 3-5% men in Western cultures 10-12% in Middle East and Southeast Asia…14% in gay men (anodyspareunia)…most experiencing it lifelong 3-5% men in Western cultures 10-12% in Middle East and Southeast Asia…14% in gay men (anodyspareunia)…most experiencing it lifelong Psychological factors play a primary role in the etiology in men Psychological factors play a primary role in the etiology in men In women, psychological factors are considered secondary, but can exacerbate pain (anxiety, depression, self-esteem, harm avoidance, somatization, shyness, and pain catastrophization) In women, psychological factors are considered secondary, but can exacerbate pain (anxiety, depression, self-esteem, harm avoidance, somatization, shyness, and pain catastrophization)

Brotto & Klein (2007) Vaginismus Vaginismus An unwanted involuntary spasm of the vaginal muscles that prevents intercourse An unwanted involuntary spasm of the vaginal muscles that prevents intercourse Often a phobic avoidance and anticipation or fear of pain Often a phobic avoidance and anticipation or fear of pain 1-6% of women 1-6% of women Highly comorbid with dyspareunia Highly comorbid with dyspareunia Behavioral theory views it as a conditioned reaction during a single sexual encounter (sexual assault) or over reapted trials (having sex with dyspareunia) Behavioral theory views it as a conditioned reaction during a single sexual encounter (sexual assault) or over reapted trials (having sex with dyspareunia) Physiological view considers it a pelvic floor dysfunction Physiological view considers it a pelvic floor dysfunction Interactional view suggests it maintains balance between partners Interactional view suggests it maintains balance between partners Male partners are passive, dependent, anxious, and lacking in self- confidence, who often suffer from their own SD, therefore vaginismus maintains a balance in a sexless relationship Male partners are passive, dependent, anxious, and lacking in self- confidence, who often suffer from their own SD, therefore vaginismus maintains a balance in a sexless relationship Multidimensional view looks at many factors Multidimensional view looks at many factors

Brotto & Klein (2007) Paraphillas Paraphillas Recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Brotto & Klein (2007) Exhibitionism Exhibitionism Recurrent and intense sexually arousing fantasies, sexual urges, or behaviors of exposing ones genitals to an unsuspecting stranger over a period of at least 6 months Recurrent and intense sexually arousing fantasies, sexual urges, or behaviors of exposing ones genitals to an unsuspecting stranger over a period of at least 6 months Most commonly reported paraphilia Most commonly reported paraphilia Victims usually women, including children Victims usually women, including children It’s the victims shock that is sexually arousing to the perpetrator It’s the victims shock that is sexually arousing to the perpetrator Don’t appear to differ from the general population on various traits Don’t appear to differ from the general population on various traits

Brotto & Klein (2007) Fetishism Fetishism Recurrent sexual arousal toward nonliving objects that are present for at least 6 months and accompanied by impairment Recurrent sexual arousal toward nonliving objects that are present for at least 6 months and accompanied by impairment Largely a disorder of men Largely a disorder of men Pretty much any object you can think of can be an object of fetish Pretty much any object you can think of can be an object of fetish

Brotto & Klein (2007) Frotteurism Frotteurism Sexual arousal involving touching and rubbing against nonconsenting individuals Sexual arousal involving touching and rubbing against nonconsenting individuals Distress and impairment not necessary if the individual acted on it (similar to exhibitionism in this regard) Distress and impairment not necessary if the individual acted on it (similar to exhibitionism in this regard) Generally takes place in crowded places Generally takes place in crowded places Typically fantasizes about having a sig. relationship with victim Typically fantasizes about having a sig. relationship with victim Mainly occurs in men Mainly occurs in men

Brotto & Klein (2007) Pedophilia Pedophilia Sexual arousal toward a prepubescent child, over the course of 6 months, must have experienced distress, or have acted on the urges Sexual arousal toward a prepubescent child, over the course of 6 months, must have experienced distress, or have acted on the urges Must be at least 16, and at least 5 years older than the prepubescent target of arousal Must be at least 16, and at least 5 years older than the prepubescent target of arousal Child molesters do not suffer from higher rates of psychopathology than non-molesters, although about 50% experienced sexual abuse as a child Child molesters do not suffer from higher rates of psychopathology than non-molesters, although about 50% experienced sexual abuse as a child May lack empathy towards their victims, but not in general May lack empathy towards their victims, but not in general Originally viewed to be only a disorder of men, data now emerging on females Originally viewed to be only a disorder of men, data now emerging on females

Brotto & Klein (2007) Sexual Masochism Sexual Masochism Sexual arousal in response to being humiliated, bound, or beaten, for at least 6 months and suffer impairment, the arousal must be in response to actual, not simulated humiliation, bondage, or beatings Sexual arousal in response to being humiliated, bound, or beaten, for at least 6 months and suffer impairment, the arousal must be in response to actual, not simulated humiliation, bondage, or beatings Most sexual masochists use little or no pain, more so through the loss of control Most sexual masochists use little or no pain, more so through the loss of control Can lead to serious injury and death (especially in the case of hypoxyphilia) Can lead to serious injury and death (especially in the case of hypoxyphilia) 20:1 males: females 20:1 males: females Appears to be modern compared to other paraphilias, as well as limited to Western cultures Appears to be modern compared to other paraphilias, as well as limited to Western cultures More common with individual with higher income More common with individual with higher income No relationship between sexual masochism and non-sexual forms of masochism No relationship between sexual masochism and non-sexual forms of masochism Tend to be well-adjusted, and often quite successful, and above norms on measures of mental health Tend to be well-adjusted, and often quite successful, and above norms on measures of mental health

Brotto & Klein (2007) Sexual Sadism Sexual Sadism Recurrent sexual arousal over 6 months in response to fantasies, urges, or behaviors involving the psychological or physical suffering of another, these must have been carried out, must be distressing, or cause interpersonal difficulty Recurrent sexual arousal over 6 months in response to fantasies, urges, or behaviors involving the psychological or physical suffering of another, these must have been carried out, must be distressing, or cause interpersonal difficulty Can lead to serious injury of death (specifically when there is comorbid ASPD) Can lead to serious injury of death (specifically when there is comorbid ASPD) More common in men than women More common in men than women

Brotto & Klein (2007) Transvestic Fetishism Transvestic Fetishism Specific to heterosexual men, 6 months of recurrent sexual arousal associated with wearing women’s clothing and accompanied by sig. distress Specific to heterosexual men, 6 months of recurrent sexual arousal associated with wearing women’s clothing and accompanied by sig. distress May experience gender dysphoria, although many are happy with their gender and only cross-dress in sexual situations May experience gender dysphoria, although many are happy with their gender and only cross-dress in sexual situations Tend to be relatively masculine Tend to be relatively masculine

Brotto & Klein (2007) Voyeurism Voyeurism Recurrent, intense sexual arousal of seeing unsuspecting people naked, in the process of undressing, or engaging in sexual activity Recurrent, intense sexual arousal of seeing unsuspecting people naked, in the process of undressing, or engaging in sexual activity Must have acted on the urges, or has caused impairment Must have acted on the urges, or has caused impairment Tend to have deficits in social and assertiveness skills as well as sexual knowledge Tend to have deficits in social and assertiveness skills as well as sexual knowledge

Brotto & Klein (2007) Theories Theories All lacking in data, however, provides some theoretical explanations All lacking in data, however, provides some theoretical explanations Neurological deficits Neurological deficits Neurological abnormalities in the temporal lobe and limbic area Neurological abnormalities in the temporal lobe and limbic area Although, many studies have found temporal lobe disorders are associated with hyposexuality, as opposed to hypersexuality Although, many studies have found temporal lobe disorders are associated with hyposexuality, as opposed to hypersexuality

Brotto & Klein (2007) Social Social Childhood abuse Childhood abuse Doesn’t account for the many individuals who suffered child abuse and did not go on to develop paraphilias Doesn’t account for the many individuals who suffered child abuse and did not go on to develop paraphilias Cognitive-Behavioral Cognitive-Behavioral Operant and classical conditioning Operant and classical conditioning Sexual arousal can be conditioned, however, extinction occurs easily Sexual arousal can be conditioned, however, extinction occurs easily Role of cognitions Role of cognitions Minimization and denial of harm, which disinhibits individuals to act on their initial paraphilic interests and then serves to maintain them Minimization and denial of harm, which disinhibits individuals to act on their initial paraphilic interests and then serves to maintain them