1. Chapter Fourteen Challenges to Sexual Functioning

2. Agenda  Sexual Dysfunctions: Definitions, Causes, and Treatment Strategies  Discuss Sexual Desire Disorders  Discuss Sexual Arousal Disorders  Discuss Orgasm Disorders  Discuss Pain Disorders  Review Illness, Disability, and Sexual Functioning  Describe Resources for Getting Help

3. Self Reflection Exercise Do NOT discuss. Write down your thoughts privately.  If I were unable to have an orgasm or an erection, what would I do?  If my partner were unable to have an orgasm or an erection, what would I do?  If a friend were experiencing a sexual dysfunction, what advice would I give to him or her?

4. Sexual Dysfunctions: Definitions, Causes, and Treatment Strategies Psychological Factors in Sexual Dysfunction Physical Factors in Sexual Dysfunction Categorizing the Dysfunctions Treating Dysfunctions

5. View “The Mango” Episode from Seinfeld  What factors contribute to George’s inability to have an erection?  Why does the fact that Elaine faked orgasms with Jerry bother him?

6. Sexual Dysfunctions: Definitions, Causes, and Treatment Strategies  The Diagnostic and Statistical Manual (DSM IV-TR) classifies sexual dysfunctions  It provides descriptions, diagnoses, treatments, and research findings  Note: there is a distinction between Sexual problems vs. sexual dysfunctions  Common sexual problems – not enough foreplay, lack of enthusiasm, inability to relax  Dysfunction – disturbance in the sexual response that doesn’t go away by itself

7. Psychological Factors in Sexual Dysfunction  Psychological factors can interfere with sexual functioning: fears, stress, anxiety, depression, guilt, anger, partner conflict, dependency, loss of control, time pressures, distractions  Performance fear – excessive need to please a partner  Spectatoring – acting as an observer or judge of one’s own sexual performance

8. Physical Factors in Sexual Dysfunction  Sexual dysfunction increases with age  Disease, disability, illness, and use of prescription and non-prescription drugs can all lead to sexual dysfunctions

9. Categorizing the Dysfunctions  Categorization helps determine appropriate treatment strategies  Primary – one that always existed  Secondary – one that develops after a period of adequate functioning  Situational – occurs during certain sexual activities or with certain partners  Global – occurs in every situation

10. Treating Dysfunctions  Medical history and workup are taken first to determine physiological causes  Evaluations of past sexual abuse or trauma  Plan for treatment is made after causes have been uncovered  Treatment may involve several therapy types  Highest success rates are 60% for primary erectile disorder, 97% for premature ejaculation, 80% for female orgasmic disorder

11. Sexual Desire Disorders Hypoactive Sexual Desire Treating Sexual Desire Sexual Aversion

12. Sexual Desire Disorders  Often considered the most difficult sexual dysfunction category to treat  Two types:  Hypoactive Sexual Desire  Sexual Aversion

13. Hypoactive Sexual Desire  Diminished or absent feelings of sexual interest in sexual activity  Problem may be due to discrepancy in desire between the partners  33% of women, 16% of men report a lack of interest; increases with age for women  Secondary is more common than primary  Psychological causes: lack of attraction to partner, fear of intimacy/pregnancy, relationship conflicts, depression, mental disorders, negative body image

14. Hypoactive Sexual Desire  Other causes: anorexia, sexual abuse, and coercion, drug abuse  Biological causes: hormonal problems, illness, medication side effects  Treatment: sex and marital therapy, cognitive-behavioral therapy, testosterone for those with low levels

15. Sexual Aversion  Strong disgust or fear to a sexual interaction  Relatively rare; affects more women than men  Often associated with childhood sexual abuse or trauma, as well as anorexia  Need to uncover the underlying conflict  Treatment: cognitive-behavioral therapy, goal setting, homework assignments (alone and with a partner)

16. Sexual Arousal Disorders Female Sexual Arousal Disorder Male Erectile Disorder

17. Sexual Arousal Disorders  More commonly sexual arousal disorders are secondary  They occur even with enough focus, intensity, and duration of sexual stimulation  Two types:  Female Sexual Arousal Disorder  Male Erectile Disorder

18. CNN Video: Female Sexual Dysfunction

19. Female Sexual Arousal Disorder  Inability to lubricate or stay lubricated  Increases with age and is common after 50  Physiological factors: lowered blood flow to the vulva  Psychological factors: fear, guilt, anxiety, depression  Treatment: Viagra™, vasoactive agents (pills, creams), herbal drugs, EROS clitoral therapy device, psychological therapy

20. The EROS-CTD is a handheld device that increases blood flow to the clitoris. The plastic cup is placed directly over the clitoris.

21. Erectile Dysfunction: Clark

22. Male Erectile Disorder  Persistent inability to get or keep an erection sufficient for satisfactory sexual performance  30 million men in the U.S.; increases with age  Physiological factors: neurological, endocrine, vascular, muscular problems  More common in older men (60+)  Psychological factors: fear of failure, performance anxiety  More common in younger men (20-35)

23. Male Erectile Disorder  Nocturnal penile tumescence test  Diagnostic tests examine erections that naturally occur during REM sleep to determine if the cause is physical (no erection) or psychological (erection)  3 nights in lab attached to machines  RigiScan™ home device  Stamp tests

24. Male Erectile Disorder  Most treatment options of any sexual dysfunction  Success rates range from 50-80%  Psychological treatment: systematic desensitization, education, sensate focus, communication training, relationship therapy

25. Male Erectile Disorder  Pharmacological treatment: Viagra™, Cialis, Levitra  Relax penile muscles, dilate penile arteries  Erection does not occur without stimulation  Must be taken 15-60 minutes prior to intercourse  Erections can last 4-48 hours  Many side effects

26. Male Erectile Disorder  Hormonal treatments help those with low testosterone levels  Testosterone patch applied to the scrotum, gels & creams to other body parts  Intracavernous injections are self-injected into the corpora cavernosa, while the penis is stretched, and causes the vessels to relax  Minor pain & possible priapism side effect  Prostaglandin pellets put into penile opening

27. Male Erectile Disorder  Vacuum Constriction Devices – suction is used to produce erections  Flaccid penis is inserted into the pump & a constriction ring is put on the base of the penis after removing it from the vacuum  When the ring is removed, the penis will become flaccid  Side effects: possible bruising, testicular entrapment

28. Vacuum constriction devices, such as the ErecAid, are often used in the treatment of ED. A man places his penis in the cylinder and vacuum suction increases blood flow to the penis.

29. Male Erectile Disorder  Surgical treatments  Revascularization  Prosthesis implants allow for orgasm, ejaculation, & impregnation  Semirigid rods – permanent erection, but can be bent up & down  Inflatable devices – patient pumps it up  10-25% of patients remain dissatisfied, dysfunctional, or sexually inactive

30. Orgasm Disorders Female Orgasmic Disorder Male Orgasmic Disorder Premature Ejaculation Retarded Ejaculation

31. Female Orgasmic Disorder  Has been referred to as “frigidity”  Delay or absence of orgasm following normal sexual excitement  A common complaint: 24% of women  Those with female orgasmic disorder tend to have more negative attitudes about masturbation, feel more guilt about sex, believe more sexual myths, & have difficulty telling their partner their needs

32. Female Orgasmic Disorder  Psychological factors: lack of sex education, fear, anxiety, personality disorders  Physical factors: chronic illness & disorders, diabetes, neurological problems, hormone deficiencies, prescription drugs, alcoholism  Treatments: homework assignments, sex education, communication skills, cognitive restructuring, desensitization

33. Female Orgasmic Disorder  Most effective treatment is masturbation training  teach to masturbate to orgasm  can include self-exploration, body awareness, experimenting with touch, vibrator, and/or with her sexual partner  Systematic desensitization and bibliotherapy help when there is a high amount of anxiety

34. Male Orgasmic Disorder  Delay or absence of orgasm following normal sexual excitement phase  8% of men  Psychotropic medications may be a cause  Treatment: psychotherapy, changing medications

35. Premature Ejaculation  A man reaching orgasm just prior to, or immediately after, penetration  Not viewed as a problem in cultures where only male pleasure is considered important  Frequency: 30% of men in a given year  Related factors: depression, drug/alcohol abuse, personality disorders

36. Premature Ejaculation  May create a biological advantage to impregnate many women in a short amount of time  May be from early sexual experiences that were rushed due to fear of being caught conditioning an early ejaculation  Men may be unable to accurately judge their level of sexual arousal

37. Premature Ejaculation  Treatments involve stimulating the penis until just before ejaculation, alone or with a partner  Squeeze technique – when stimulation is stopped, pressure is applied to the base for 3-4 seconds, until the urge drops; repeated  Stop-start technique – stimulation is stopped until urge subsides; repeated many times  Need to use the techniques for 6-12 months  Improvements often subside within 3 years

38. The squeeze technique is often recommended in the treatment of premature ejaculation. Pressure is applied at either the top or base of the penis for several seconds until the urge to ejaculate subsides.

39. Retarded Ejaculation  A man may not reach orgasm during certain sexual activities or may only ejaculate after prolonged (30-45 minutes) stimulation  Physical factors: diseases, injuries, drugs  Psychological factors: strict religious upbringing, unique masturbation patterns, sexual orientation ambivalence  Situational factors  Difficult to treat; often use psychotherapy

40. Pain Disorders Vaginismus Dyspareunia and Vulvodynia

41. Vaginismus  Involuntary contractions of the pubococcygeus muscle surrounding the vaginal entrance  Makes penetration nearly impossible  May be situation specific  Contractions are in reaction to anticipated vaginal penetration  Common in sexually abused or raped women  Often co-occurs with other sexual difficulties

42. Vaginismus  Treatments  Dilators are used to help open and relax the muscles, which is 75-100% effective  Education  Reduce anxiety and tension  Work through previous trauma

43. Dyspareunia and Vulvodynia  Dyspareunia is pain during intercourse  Pain may range from slight to severe  May occur before, during, or after intercourse  15% of women  Men can experience pain in the testes or penis  Physical factors: allergies, infections  Psychological factors

44. Dyspareunia and Vulvodynia  Vulvar vestibulitis syndrome, a type of vulvodynia, is a common cause of dyspareunia in women  Peyronie’s disease may be a leading cause of dyspareunia in men  Treatments: medical treatments, psychotherapy, biofeedback, surgery

45. Illness, Disability, and Sexual Functioning Cardiovascular Problems Cancer Chronic Illness & Chronic Pain Diabetes Multiple Sclerosis Alcoholism Spinal Cord Injuries AIDS & HIV Mental Illness & Retardation

46. Illness, Disability, and Sexual Functioning  Physical illness can interfere with sexual functioning due to physiological changes, as well as psychological changes & relational changes  Disabled women have more difficulties, however, research has focused on men  Illnesses and disabilities:  Cardiovascular Problems  Cancer

47. Illness, Disability, and Sexual Functioning  …Continued  Chronic Illness and Chronic Pain  Chronic Obstructive Pulmonary Disease  Diabetes  Multiple Sclerosis  Alcoholism  Spinal Cord Injuries  AIDS and HIV  Mental Illness and Retardation

48. Cardiovascular Problems: Heart Disease and Stroke  Heart disease is the primary cause of death in the U.S.  A person can return to normal sex about 4-8 weeks after recovery, however, intercourse tends to decrease  Reasons for the decrease: fear, erectile difficulties, depression, feelings of inadequacy, loss of attractiveness, partner becomes the caretaker

49. Cardiovascular Problems: Heart Disease and Stroke  Stroke – blood is cut off from part of the brain  Can create memory, perceptual, & cognitive problems, but usually not affect sexual functioning  Problems stem from: fear, worries about attractiveness, stress, anxiety, some erections may be crooked, jerking motions, reduced sensation, communication problems  May cause hypersexuality or hyposexuality

50. Cancer Breast Pelvic Prostate Testicular

51. Cancer  Cancer produces feelings of shock, depression, numbness, & fear  Partners may change roles  Cancer can decrease sexual activity, even if it does not affect sexual organs  Ostomies can be hard for many to accept  Scars, loss of body parts, changes in skin & hair, nausea, weight change, and bloatedness can all inhibit sexual relations

52. Breast Cancer  Much of a woman’s self-image can be invested in her breasts  Removal of all or part of a breast or both can alter a woman’s self-image and sexual identity  Many women may wear a prosthesis, undergo breast reconstruction, or have implants

53. Pelvic Cancer and Hysterectomies  Cancer of the vagina, cervix, uterus, & ovaries can affect a woman’s sexual response  She may undergo a hysterectomy, which is currently the most common medical procedure in the U.S.  The surgery may cause nerve damage  It may also improve sexual functioning

54. Pelvic Cancer and Hysterectomies  Removal of ovaries will create a hormonal imbalance that can reduce lubrication, cause mood swings, other bodily changes  Removal of the uterus may decrease pleasure during orgasm that was obtained through contractions of the uterus  If the vagina is shortened, it may make intercourse more painful  Some may mourn the loss of a body part, female identity, or the ability to have kids

55. Prostate Cancer  Most men will have enlargement of the prostate gland as they age  Prostate cancer is one of the most common in men over 50  Prostatectomy may be performed  May cause incontinence and necessitate a catheter  May cause erectile dysfunction

56. Testicular Cancer  A testicle may be removed (orchiectomy), which can make a man feel that he has lost part of his manhood and become concerned about the appearance of his scrotum  Prosthesis may take the place of the missing testicle  Penectomy may occur in rare cases of cancer of the penis

57. Chronic Illness and Chronic Pain  Arthritis, migraine headaches, & lower back pain can make intercourse difficult or impossible

58. Chronic Obstructive Pulmonary Disease  This includes asthma, tuberculosis, chronic bronchitis, and emphysema  Physical exertion may be difficult  Perceptual and motor skills may be impaired

59. Diabetes  Pancreas cannot make insulin or the body cannot use the insulin that is produced  Insulin processes blood sugar into energy  Often creates many sexual difficulties  Erection difficulties, vaginitis, yeast infections  Many diabetic men receive penile prostheses  Both physiological and psychological problems often play a part

60. Multiple Sclerosis  Breakdown of the myelin sheath that surrounds & protects nerve fibers  Symptoms: dizziness, blurred vision, muscle spasms, loss of control of muscles, weakness  60-80% of men with MS experience ED  Women with MS may lack vaginal lubrication, have difficulty attaining orgasm  Many may be hypersensitive to touch  Treatments: therapy, prostheses, lubrication

61. Alcoholism  Alcohol is a nervous system depressant with long & short term effects on sexual operations  May impair spinal reflexes, decrease testosterone, lead to erectile dysfunction  In men may cause feminization, gynecomastia, testicular atrophy, sterility, ED  In women may cause decreased menstrual flow, ovarian atrophy, loss of vaginal membranes, miscarriages, infertility

62. Spinal Cord Injuries  Damage can cut off impulses in areas served by nerves below the damaged section  Depending on where the injury occurred, & the extent of the damage, a man may still be able to have an erection through a reflex action responding to stimulation, however, he is not likely to orgasm or ejaculate  Likely to make a person dependent on his/her partner or caretaker

63. Spinal Cord Injuries  Women can remain fertile and bear children  Women may also lose sensation & ability to lubricate  Spinal cord injuries may create new erogenous zones  Typically, sexual activity decreases after the injury  Preferred sexual activities tend to change to kissing, hugging, & touching

64. Spinal Cord Injuries  Couples can still use their mouths & possibly hands to pleasure their partner  “Stuffing” may also be used  Treatment methods include prosthesis implantation, vacuum erection devices, injection of vasoactive drugs, & Viagra™

65. AIDS and HIV  Those infected often fear infecting others, are shamed, and may stop all sexual activity  Other may limit their sexual activity to hugging, kissing, & touching  Care needs to be taken to avoid exchanging bodily fluids & keeping clean  Sexual relations can still occur while remaining safe

66. Mental Illness and Retardation  Those with psychiatric disorders have been treated as asexual or as perverts  Those institutionalized are discouraged from masturbating, though each institution differs  Special sexuality education programs are designed for those with mental retardation & those that are developmentally disabled  Denying sexuality in these cases is needless  Sexual exploitation can also occur

67. Getting Help  Seek help as soon as possible  Most colleges have a student counseling center  You may wish to seek a sex therapist trained by the American Association of Sexuality Educators, Counselors, and Therapists (AASECT)