• Sexual dysfunctions = persistent disruptions in the ability to experience sexual arousal, desire or orgasms, or pain associated with intercourse
  • Paraphilic disorders = persistent and troubling attractions to unusual sexual activities or objects

Sexual Norms and Behaviour

  • Inhibition of sexual expression is seen as a problem
  • Used to be that excessive masturbation in childhood widely believed to lead to sexual problems in adulthood o Victorian view – sexual appetite is dangerous and must be restrained

o Corn Flakes and Graham Crackers were developed as foods that would lessen sexual interest (failed to do so)

  • New easy accessibility to sexual content using technology
  • Newer STIs related to increased risk with sexual activity
  • Newfound emphasis on right to a good sex life until the day one dies *increasing array of medications to promote this
  • Culture influences attitudes and beliefs: important part of well-being vs. for procreation only

Gender and Sexuality

  • Men report more engagement in sexual thought and behaviour than women o More thinking about sex, masturbating, and desiring sex more often
  • Women tend to be more ashamed of any flaws in their appearance, can interfere with sexual satisfaction
  • For women sexuality is more closely tied to relationship status *less sexual drive and masturbating when not in relationship
  • More than half of women with sexual dysfunction believe it is caused by relationship problems
  • Men think about their sexuality in terms of power
  • Primary motivation for having sex: sexual attraction and physical gratification
  • Women are much more likely to report symptoms of sexual disorders
  • Men are much more likely to meet criteria for Paraphilic disorder The Sexual Response Cycle

1) Desire phase = sexual interest or desire, often associated with sexually arousing fantasies or thoughts

2) Excitement phase = men and women experience increased blood flow to genitalia (produces erection in male penis & enlargement of breasts & increased lubrication in female vagina)

3) Orgasm phase = sexual pleasure peaks, male ejaculation almost always occurs, in women the outer walls of the vagina contract (general muscle tension)

4) Resolution phase = relaxation and sense of well-being that usually follows orgasm o Men – associated refractory period during which further erection isn’t possible o Women often able to respond again immediately

  • Many women report that desire and excitement co-occur and cannot be made distinct
  • Vaginal plethysmograph = used to measure women’s physiological arousal o Amount of blood flow has little correlation to subjective level or desire/excitement
  • Sexual Dysfunctions (SD) Clinical Descriptions

 Symptoms must last at least 6 months (common to have for just a month)  3 categories:

  • Involving sexual desire, arousal, and interest (low sex drive)
  • Women: female sexual interest/arousal disorder o 1) Diminished, absent or reduced frequency of at least 3 of the following:
    • Interest in sexual activity, erotic thoughts/fantasies, initiation of sexual activity & responsiveness to partner’s attempts to initiate, sexual excitement/pleasure during 75% of sexual encounters, sexual interest/arousal elicited by any internal or external erotic cues, genital or non-genital sensations during 75% of sexual encounters
    • Overall, deficits in sexual interest, biological arousal or subjective arousal
  • Men: male hypoactive sexual desire disorder o 1) Sexual fantasies and desires, as judged by clinician, are deficient or absent
  • Men: erectile disorder o On at least 75% of sexual occasions:
    • 1) Inability to attain an erections, or
    • 2) Inability to maintain an erection for completion of sexual activity, or
    • 3) Marked decrease in erectile rigidity interferes with penetration or pleasure o 13-28% rates o Prevalence increases with age (50% are 60+)
  • More than 50% seeking treatment report low desire, women more likely than men to report
  • 2-4x more likely if post-menopausal *although older women are less likely to be distressed about it
  • Women more concerned about lack of subjective desire *previously arousing stimuli no longer affective
  • Often have normative biological arousal even with lack of subjective desire
  • Dysfunction should be persistent and recurrent and should cause clinically significant distress or problems with functioning o Diagnosis not made if cause is entirely due to a medical illness (e.g. advanced diabetes) or other psyc disorder
  • More women than men report symptoms of sexual dysfunction (43% vs. 31%)
  • Clinical diagnosis not made unless symptoms cause distress/impairment (only 11-23% of women) Orgasmic disorders
    • Women: female orgasmic disorder o On at least 75% of sexual occasions:
    • 1) Marked delay, infrequency, or absence of orgasm, or
    • 2) Markedly reduced intensity of orgasmic sensation o 1/3 of females report they do not consistently have orgasms with their partners
    • Men: Premature ejaculation o 1) Tendency to ejaculate during partnered sexual activity within 1 minute of penile insertion on at least 75% of occasions
    • Delayed ejaculation o 1) Marked delay, infrequency, or absence of orgasm on t least 75% of sexual occasions o Least common

III. Sexual pain

  • Women: Genito-pelvic pain/penetration disorder o Persistent or recurrent difficulties with at least one of the following:

1) Inability to have vaginal/penetration during intercourse

2) Marked vulvar, vaginal, or pelvic pain during vaginal penetration or intercourse attempts

3) Marked fear or anxiety about pain or penetration

4) Marked tensing of the pelvic floor muscles during attempted vaginal penetration o Vaginismus = involuntary muscle spasms o the outer third of the vagina, making intercourse impossible

  • Make sure pain is not caused by infection or lack of lubrication
  • Can still have sexual arousal and reach orgasm from manual/oral stimulation

Etiology of Sexual Dysfunction

  • 2 causes: fears about performance and adoption of spectator role
  • Fears about performance – concerns with how one is performing during sex
  • Spectator role – being an observer rather than a participant in a sexual experience

Biological Factors

  • Separate category for sexual dysfunctions caused by medical illness (diabetes, MS, spinal cord injury, heavy alcohol use before sex, heavy cigarette smoking)
  • Can be caused by low levels of testosterone/estrogen or high levels induced by anabolic steroids or testosterone supplements
  • SSRIs and antihypertensive drugs have effects on sexual function:
    • Delayed orgasm, decreased libido, diminished lubrication
  • Erectile symptoms often elated to incipient vascular disorder

Psychosocial Factors

  • Some sexual dysfunctions can be traced to rape/sexual abuse o Childhood sexual abused associated with diminished arousal/desire, and premature ejaculation in men
  • For women – concerns about partner’s affection correlated with sexual satisfaction
  • Anxiety and anger, poor communication, embarrassment, fears
  • Increased risk if have depression/anxiety and panic disorder
  • Anxiety/depression comorbid with sexual pain
  • Negative cognitions
  • People who blame themselves for decreased sexual performance are more likely to develop dysfunction symptoms o Later experience diminished arousal Treatment

 

Begin by resolving any relationship problems – training in non-sexual communication skills and nonsexual issues o Difficulties with in-laws, child rearing

Recommend planning romantic events together to restore closeness and intimacy

  • Behavioural couples therapy especially effective for women
  • Sensate focus – reestablish sexual intimacy through contact

Anxiety Reduction and Psychoeducation

  • Systematic desensitization and in vivo desensitization (begin with psychoeducation, then using small dilator, then larger)
  • Psychoeducation – videos showing sexual techniques
  • For premature ejaculation – expand repertoire of activities

Procedures to Change Attitudes and Thought

  • Sensate-focus exercises
  • Help focus on physical sensations

Communication Training

  • Communicate likes and dislikes to one another
  • Expressing sexual preferences
  • **Used when dysfunction is specific to a given relationship and not a concern with previous partners

Directed Masturbation

  • Developed to enhance a women’s comfort with and enjoyment of sexuality
  • Women carefully examines her nude body, identify various areas, instructed to touch her genitals, find areas that produce pleasure
  • Increase intensity using erotic fantasies, if no orgasm, use vibrator, let her partner do for her as she was doing
  • Helpful for treating orgasmic disorders

Other Physical Treatments

  • Learn sexual positions that increase clitoral stimulation (for female orgasmic disorder)
  • Squeeze technique (premature ejaculation)

Medications

  • Testosterone therapy (not approved by FDA for female) – sexual interest/arousal disorder  Psychotherapy is helpful alongside medication  Antidepressants:
    • Helpful is depression contributes to diminished sex drive
    • Particularly use SSRIs – also helpful in treatment of premature ejaculation o Some actually interfere with sexual responsiveness, use 2nd medication e.g. buproprion  PDE-5 inhibitors:
    • Phosphodiesterase type 5 inhibitor *treatment for erectile disorder
    • Relax smooth muscles and allow blow to flow into penis, creating erection during sexual stimulation but not in its absence
    • Taken 1 hour before sex, effects last 4 hours o Side effects: headaches, indigestions
    • May be dangerous with cardiovascular disease (often comorbid)

Paraphilic Disorders

  • = Recurrent sexual attraction to unusual objects or sexual activities lasting at least 6 months
  • 1 category for people whose sexual attractions are focused on causing pain & another for those focused on children

When termed “disorder” – diagnoses are to be considered only when the sexual attractions cause marked distress or impairment or when the person engages in sexual activities with a nonconsenting person

Objects of sexual attraction are described: o Fetishistic disorder = an inanimate object or non-genital body part o Transvestic disorder = cross-dressing o Pedophilic disorder = children

o Voyeuristic disorder = watching unsuspecting others undress or have sex o Exhibitionistic disorder = exposing one’s genitals to an unwilling stranger o Frotteuristic disorder = sexual touching of an unsuspecting person o Sexual sadism disorder = inflicting pain o Sexual masochism disorder = receiving pain

  • Lack of structured interviews to reliably assess these disorders
  • Most people with Paraphilic disorders are heterosexual males
  • Onset: adolescence (sadism and masochism in early adulthood)
  • More than 2/3 meet mood disorder criteria, anxiety/substance disorders also common

Fetishistic Disorder

    • 1) For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviours involving the use of nonliving objects or nongenital body parts
    • 2) Causes significant distress or impairment in functioning
    • 3) The sexually arousing objects are not limited to articles of clothing used in cross-dressing or to devices designed to provide tactile genital stimulation, such as a vibrator
    • Almost exclusively effects men, fetish sometimes necessary for sexual arousal
    • Clothing (underwear), leather, articles related to feet (stockings, women’s shoes) are common fetishes o Hair, nails, hands, feet are sexually arousing
    • Feel compulsive attraction to the object, involuntary and irresistible

 

  • Pedophilic Disorder and Incest
    • 1) For at least 6 months, recurrent and intense, sexually arousing fantasies, urges, or behaviours involving sexual contact with a prepubescent child
    • 2) Person has acted on these urges or the urges and fantasies cause marked distress or interpersonal problems
    • 3) Person is at least 16 years old and 5 years older than the child
    • Generally molest children they know, most don’t engage in violence other than the sexual act
    • Denies that he is forcing himself on the victim
    • 50% are adolescent males, most are heterosexual
    • Incest = sexual relations between close relatives for whom marriage is forbidden (subtype of pedophilic disorder) o Most common between brother and sister, then father and daughter o Children of incest can inherit too many recessive genes and lead to serious genetic defect o Men who commit incest usually abuse their pubescent daughters (vs. pre-pubertal) o Show greater penile arousal Voyeuristic Disorder

1) For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviours involving the observation of unsuspecting others who are naked, disrobing, or engaged in sexual activity

2) Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause marked distress or interpersonal problems

  • These fantasies are quite common among men

“Peeping” helps promote sexual arousal and is sometimes essential for it

  • Does not find it exciting to watch a women who is undressing for his benefit
  • Excited by anticipation of how the women would react is she knew he was watching

Exhibitionistic Disorder

1) For at least 6 months recurrent, intense, and sexually arousing fantasies, urges, or behaviours involving showing one’s genitals to an unsuspecting person

2) Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause clinically significant distress or interpersonal problems

  • Many masturbate during exposure
  • Desire to shock or embarrass the observer
  • Urge to expose triggered by anxiety and restlessness and well as by sexual arousal
  • Symptoms of anxiety: headaches, palpitations and Derealization
  • May be repeated often, same place, same time of day *compulsive
  • Social and legal consequences are far off of mind
  • Flee and feel remorseful after Frotteuristic Disorder

1) For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviours involving touching or rubbing against a nonconsenting person

2) Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause clinically significant distress

  • Typically occurs on a crowded bus or sidewalk that provide an easy means of escape  Report doing so a dozen times

Sexual Sadism and Masochism Disorders

Sadism Criteria

1) For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviours involving the physical or psychological suffering of another person

2) Causes clinically significant distress or impairment in functioning or the person has acted on these urges with a nonconsenting person Masochism Criteria

1) For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviours involving the act of being humiliated, beaten, bound, or made to suffer

2) Causes marked distress or impairments in functioning

  • Manifestations of masochism: physical bondage, blindfolding, spanking, whipping, electric shocks, cutting, humiliation (being urinated/defecated on, being forced to wear a collar and bark, being put on display naked), and taking the role of slave and submitting to orders and commands
  • Most sadists have relationships with masochists, or can take on both roles **masochists outnumber sadists
  • Behaviour becoming more acceptable over time
  • Found in straight and gay relationships
  • 20-30% of sadomasochistic clubs are female
  • Above average in income and educational status
  • Alcohol abuse is common among sadists

Etiology of Paraphilic Disorders Neurobiological Factors

  • Most paraphilics are male, perhaps androgens (hormones like testosterone) play a role

 

Androgens regulate sexual desire *high among sexual offenders with Paraphilic disorders

Childhood Sexual Abuse

  • 2/3 of sexual offenders reported a history of sexual abuse

Psychological Factors

  • Succumbing to sexual urge thought of as impulsive act, often occur in context of alcohol use (unable to inhibit impulses)
  • Others report often occur in context of negative moods – sexual activity used as means to escape
  • Heightened impulsivity and poor emotion regulation
  • Cognitive distortions and attitudes, lack of empathy for women
  • Distortion that a women who left her blinds up wants to be looked at, or women who dress provocatively “ask for it”
  • Men with pedophilia have lower IQ, higher rates of neurocognitive problems Treatment

Strategies to Enhance Motivation

  • Sexual offenders lack motivation to change illegal behaviour
  • Deny their problem, minimize seriousness, feel confident that they can control it
  • Blame the victim for being overly seductive
  • Enhance motivation, bolster hope that client can gain control over urges through treatment, highlight potential legal consequences

CBT

  • Aversion therapy to reduce attraction to inappropriate object/activity
  • Satiation – trained to pair Paraphilic fantasy with another aversive stimulus (masturbating for 55 minutes after orgasm)
  • Covert sensitization – person imagines situations he finds inappropriately arousing and imagines feeling sick/ashamed for feeling and acting this way *reduces deviant arousal
  • Counter distorted thinking that the subjects aren’t really being harmed
  • Social skills training, training in empathy towards others
  • Sexual impulse control training

Biological Treatments

  • Castration – removal of testes
  • Medications used as supplement to psyc treatment – hormonal agents that reduce androgens o Reduce arousal to deviant objects

o Long-term use associated with negative side effects

  • SSRIs commonly used

Balancing Efforts to Protect Public Against Civil Liberties for Those with Paraphilias

  • Unconstitutional to detain a person on basis of his/her potential for future crimes
  • High risk for sexual crime can be detained if risk is related to psyc disorder that diminished ability to control sexual behaviour
  • Allowed to find out where sexual offenders are living