1. Chapter 16 Sexual Disorders

2. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Historical Perspective St-Augustine declared that sexual intercourse was only allowed for procreation, only when the man was on top, and only when the penis and vagina were involved Many believed that masturbation caused a variety of illnesses (see Tissot, 1758) – Onania, or the Heinous Sin of Self-Pollution, And All Its Frightful Consequences, in Both Sexes, Considered was published in 19 editions and sold 38,000 copies before 1750

3. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Figure 10.3 The human sexual response cycle.

4. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Sexual Disorders: Diagnosis & Classification Must cause marked distress or interpersonal difficulty Specify: Lifelong (primary) vs. acquired (secondary) Global vs. Situational Gradual vs. Sudden onset Course: stable, improving, worsening Differentiate if secondary to a medical or psychiatric condition Physical disease Substance abuse Other Axis I disorder Medication

5. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Sexual Dysfunction Disorders Sexual desire disorders Sexual arousal disorders Orgasmic disorders Sexual pain disorders

6. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Sexual Desire Disorders Hypoactive Sexual Desire Disorder— persistently deficient or absent sexual fantasies and desires Sexual Aversion Disorder—persistently extreme aversion to, and avoidance of, sexual contact with another person

7. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Causes of low desire in women PSYCHOLOGICAL FACTORS Losses Trauma Past sexual and non-sexual relationships Cultural and religious attitudes CONTEXTUAL FACTORS Current interpersonal difficulties Partner sexual dysfunction Inadequate stimulation Unsatisfactory sexual and emotional contexts

8. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Causes of low desire in women MEDICAL FACTORS Menopause (Low androgens) Endocrine disorders (hypo-gonadism) Medical procedures (hysterectomy, radiotherapy, chemo) General poor health Fatigue Depression Lactation (prolactin) Hormone replacement therapy & oral contraceptives SSRIs & other antidepressants Antipsychotics Narcotics or other substance abuse Cardiac medications (Ca & Beta blockers)

9. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Persons with sexual arousal disorders experience sexual desire, but are unable to maintain arousal during intercourse Female sexual arousal disorder involves inadequate vaginal lubrication Male erectile disorder involves failure to maintain an erection during intercourse Can be induced by disease, drugs or depression Most common sexual problem for which men consult with specialists (50% of referrals) Sexual Arousal Disorders Ch 14.15

10. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Male Erectile Disorder (ED) Etiology Medical Diseases (diabetes, cardiovascular or prostate problems) Pelvic trauma Medications (antidepressants, anti-hypertensives) Treatments (prostate surgery, dialyses) Sexual Arousal Disorders

11. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Etiology of ED Psychological Depression Anxiety Obsessive-compulsive disorder Performance anxiety Trauma (e.g., abuse) Fear Pregnancy, STDs History of premature ejaculation Sexual orientation conflict

12. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Etiology of ED Relationship Anger Passive-aggressive Power struggle Loss of sexual interest Partner sexual dysfunction Suspected infidelity Commitment issues

13. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Female orgasmic disorder refers to the absence of orgasm after a period of normal sexual excitement Female orgasmic disorder may reflect Difficulty in learning to become orgasmic Chronic use of alcohol Fear of losing control Male orgasmic disorder refers to difficulty in ejaculation Premature ejaculation is early ejaculation Orgasmic Disorders Ch 14.16

14. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Male Orgasmic Disorder Inability to reach orgasm after sufficient stimulation Often requires manual or oral stimulation Experienced as “hard work” Rare (< 1%) Physiological etiology High orgastic threshold Other side of the curve from PEs SSRIs

15. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Male Orgasmic Disorder Psychological etiology Anxiety Including performance anxiety Depression Abuse history Relationship issues Anger

16. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Causes of anorgasmia in women BIOLOGICAL Selective serotonin reuptake inhibitors (SSRIs) Especially those with primarily serotonergic and not dopaminergic or noradrenergic effects Antipsychotic medications (that decrease dopamine) PSYCHOLOGICAL Lack of information about sexual anatomy Less education Being younger Higher religiosity  higher sex guilt High anxiety Inability to “let go”

17. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Sexual Pain Disorders Dyspareunia refers to persistent or recurrent pain during sexual intercourse Associated with depression, anxiety and marital difficulties Vaginismus refers to an inability to achieve intercourse due to involuntary spasms of the outer third of the vagina Associated with fear of pregnancy, relationship problems and negative attitudes toward sex Ch 14.17

18. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Causes of Vaginismus BIOLOGICAL FACTORS Pelvic floor muscle problems PSYCHOLOGICAL FACTORS Maintains balance in an unhealthy relationship Protest against patriarchal norms that reduce women to a lust object or a mother Conditioned anxiety response**

19. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Historical Causes of Sexual Dysfunction Religious orthodoxy involves negative views of sexuality (procreation only, not for pleasure) Psychosexual trauma Homosexual inclination: sexual desire is impaired if a homosexual engages in sex with a heterosexual Excessive alcohol intake

20. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Predisposing Factors Perpetuating Factors Precipitating Factors Early Development Current Functioning How do sexual problems develop?

21. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 How do sexual problems develop? Predisposing Childhood abuse or sexual assault Early sexual experiences Precipitating Relationship distress Major life changes such as parenthood, retirement Menopause Surgery or physical illness Perpetuating Performance anxiety Poor communication Lack of knowledge Physical response (muscle tension) Laumann, Paik, Rosen, 1999, JAMA

22. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Causes of sexual aversion A classically conditioned response Conditioned response Fear, panic, and avoidance Unconditioned stimulus Assault Conditioned stimulus Sex + 

23. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Predictors of sexual dysfunction not in relationship not college educated emotional problems stress poor health urinary tract problems substance use low SES low sexual activity sexual victimization low overall quality of life BIO SOCIAL PSYCHO age (in men)

24. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Paraphilias: DSM-IV (1994) “recurrent, intense sexually arousing fantasies, sexual urges, or behaviours generally involving 1) nonhuman objects, 2) the suffering or humiliation of oneself or one’s partner, or 3) children or other nonconsenting persons that occur over a period of at least 6 months “The urges or behaviour cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

25. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 DSM-IV cont. “…many individuals with these disorders assert that the behaviour causes them no distress and that their only problem is social dysfunction as a result of the reaction of others to their behaviour”

26. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Gender Differences Except for S-M where the sex ratio is 20:1 males: females, the other paraphilias are almost never diagnosed in women Peeping Tom 1960

27. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Fetishism Transvestitism Sexual Sadism Person uses inanimate objects as the preferred or exclusive source of sexual arousal. Fetish in which a heterosexual man dresses in women’s clothing as his primary means of becoming sexually aroused. Sexual gratification obtained through inflicting pain and humiliation on one’s partner. Paraphilias

28. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Sexual Masochism Voyeurism Sexual gratification obtained through experiencing pain and humiliation at the hands of one’s partner. Obtainment of sexual arousal by compulsively and secretly watching another person undressing, bathing, engaging in sex, or being naked. Paraphilias, continued

29. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Exhibitionism Pedophilia Obtainment of sexual gratification by exposing one’s genitals to involuntary observers. Obtainment of sexual gratification by rubbing one’s genitals against or fondling the body parts of a nonconsenting person. Frotteurism Adult obtainment of sexual gratification by engaging in sexual activities with young children. Paraphilias, continued

30. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Theories of fetish behaviour Learning theory = result from classical conditioning between fetish object and sexual arousal Cognitive theory = cognitive distortion and perceiving an unconventional stimulus as sexual Monoamine hypothesis = problems in monoamine (serotonin, norepinephrine, dopamine) metabolism

31. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Theories of fetish (cont.) Imprinting hypothesis = adolescents are vulnerable to imprinting of various stimuli; thus, experiencing a stimulus at a critical period can lead to imprinting Addiction theory = when a behaviour has salience modifies mood Tolerance Withdrawal symptoms Conflict relapse

32. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Causes of Paraphilias Psychodynamic theory Fixation at early psychosexual stage or regression to that stage. Behavioral Arousal is classical conditioned to a previous neutral stimulus. Social learning Children whose parents engage in aggressive, sexual behaviors with them learned to engage in impulsive, aggressive, sexualized acts toward others. Cognitive Distorted cognitions and assumptions about sexuality lead to deviant sexual behavior. Theory Description

33. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatments: Cognitive Behavioural Satiation  teach the individual to satiate himself with the stimulus until arousal decreases Covert sensitization  associate negative consequences to the precursors of his atypical behaviour

34. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Fading  shift fantasies from atypical to acceptable Cognitive restructuring  challenge cognitive distortions that justify to the patient his atypical behaviour Treatments: Cognitive Behavioural

35. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatments: Cognitive Behavioural Victim empathy therapy  help patients understand impact of their behaviour Aversive stimulation  pair noxious stimulus with the deviant fantasy in order to interrupt the fantasy and suppress the behaviour

36. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatments: Relapse Prevention Help individual identify factors that trigger a relapse E.g., high risk situations, behavioural chains that lead up to the problem behaviour, strategies to avoid these factors

37. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatments: 12-Step Sexaholics Anonymous Sex Addicts Anonymous Peer-lead Modelled after AA

38. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatments: Medical Antiandrogens High rate of side effects, poor patient motivation, and high drop-out rates Implant GnRH analogues (leads to lowered LH and testosterone) Medroxyprogesterone acetate Side effects: osteopenia, osteoporosis

39. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatments: Medical Selective Serotonin Reuptake Inhibitors (SSRIs) 50-90% efficacy Also targets the low mood and anxiety

40. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Other helpful adjuncts to treatment Social skills training Assertiveness skills training Sex education Couples therapy

41. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Gender Identity Disorder A person’s belief that they were born with the wrong sex’s genitals and are fundamentally persons of the opposite sex.

42. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 DSM-IV Criteria for Gender Identity Disorder A.Strong and persistent identification with the other sex. In children, this is manifest by four or more of the following: 1.Repeatedly stated desire to be, or insistence that he or she is, the other sex; 2.In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing; 3.Strong and persistent preferences for cross-sex roles in play and in fantasies; 4.Intense desire to participate in the stereotypical games and pastimes of the other sex; 5.Strong preference for playmates of the other sex.

43. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 DSM-IV Criteria for Gender Identity Disorder, continued B. Persistent discomfort with his or her sex and a sense of inappropriateness in the gender role of that sex. C. Disturbance is not concurrent with a physical intersex condition and causes significant distress or problems.

44. Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved. Chapter 16 Treatment of Gender Identity Disorder Therapists do not try to “cure” people with gender identity disorder by convincing them to accept the body with which they were born. Gender reassignment requires several surgeries and hormone treatments and is primarily cosmetic. It remains a controversial practice.