Chapter 10- Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria PDF

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Chapter 10: Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria• Common Myths About Sex Men will never turn down a chance to have sex Older adults are asexual Sex is always pleasurable We’re all comfortable with sex Sex equals intercourse All touching should lead to sex Women should have...

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Chapter 10: Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria

• Common Myths About Sex • Men will never turn down a chance to have sex • Older adults are asexual • Sex is always pleasurable • We’re all comfortable with sex • Sex equals intercourse • All touching should lead to sex • Women should have mind-blowing orgasms • Men can have as many partners as they’d like but women shouldn’t • Gay men have lots of sex

• Consequences • Unrealistic expectations – anxiety/shame around not meeting these standards • Pressure to perform and/or have an orgasm – takes away pleasure of activity

• Sexual Dysfunction – difficult to function adequately during sex (ex. inability to become aroused or reach orgasm) • Occurs in both heterozygous and homozygous relationships • Life-long – chronic condition present throughout person’s entire sexual life • Acquired – begins after sexual activity has been relatively normal • Generalized – occurs every time individual attempts sex • Situational – only with certain partners, certain times, etc. • Current Severity – rating based on amount of dysfunction present • One of the most prevalent of all psychological or physical disorders • Takes into account age, ethnicity, distress level • Persistent problem at phase(s) of sexual response cycle; 6(+) months • Clinically significant distress or impairment • Other factors to consider – culture, relationship, depression, medical factors, personal factors (ex. body image) • Only when there are none of these other factors involved can it be considered a disorder • MUST be distressed over the problem, otherwise it would not be considered a disorder (but rather just a sexual problem) • Examples

• Single male, no desire to engage in sexual activity either alone or with a partner – no (not distressed about it) • Couple who needs to engage in sex at least 5 times a day – yes (impairs day to day functioning) • Couple where neither partner wants to engage in sexual activity – (could be fine if neither is distressed) • Single female, searches for anonymous sex partners online – (could be fine if there’s no distress or harm to herself) Sexual Response Cycle

• Kaplan Model • Desire —> Arousal —> Orgasm • Desire – sexual urges occur in response to sexual cues or fantasies; interest in sexual activity • Arousal – subjective sense of sexual pleasure and physiological signs of sexual arousal; psychological/physiological excitement • Plateau Phase – brief period occurs before orgasm • Orgasm – feelings of inevitability of ejaculation, followed by ejaculation (males); contractions of walls of lower third of vagina (females); climax • Resolution Phase – decrease in arousal occurs after orgasm(particularly in men)

• Basson Model • Desire (Sexual Incentives —> Receptivity —> Processing of Stimuli) —> Arousal —> Orgasm • Women who bought into this model (more than the other) had more sexual dysfunctions • Should sexual problem be identified as a diagnosis when dysfunction is clearly present but person is not distressed about it? • Occasional or partial sexual dysfunctions are easily accommodated in healthy relationships • DSM-5 – symptoms must clearly cause clinically significant distress in individual Desire Disorders

• Male Hypoactive Sexual Desire Disorder – little or no interest in sex that’s causing significant distress in individual • May gauge sexual desire by frequency of sexual activity or sexual fantasies • Ex. but person might have sex twice a week but have no desire, only doing it because his wife wants to have more sex

• Prevalence increases with age – rapidly in men after age 60

• Female Sexual Interest/Arousal Disorder – deficits in interest or ability to become aroused (desire + arousal phases); “frigidity” • In females, low sexual interest almost always accompanied by diminished ability to become excited/aroused by erotic cues or sexual activity • Females complain more about low sexual desire, whereas men complain more about erectile dysfunction • Prevalence decreases with age • Deficits in arousal reflected in inability to achieve/maintain adequate lubrication • Many women don’t consider absence of arousal a problem, let alone a disorder • Low motivation, lack of pleasure • Ex. parents were very protective, never allowed to get close to boys, first date had to be chaperoned, met a boy who she had sex with few months after dating, man ejaculated one minute into sex, she was disappointed and didn’t have orgasm, found out she was pregnant (negative connotation) Arousal Disorders

• Erectile Disorder – unable to become aroused despite having frequent sexual urges, fantasies, and strong desire to have sex; “impotence”; any of the following three symptoms for over 6 months continuously • Difficulty obtaining erection • Difficulty maintaining erection • Decrease in erectile rigidity Orgasm Disorders • Male Orgasmic Disorder – unable to ejaculate with partner, but can obtain erection and ejaculation during masturbation • Female Orgasmic Disorder – female version; can’t achieve orgasm or reduced intensity of orgasm • Despite adequate sexual desire and arousal • Delayed/Retarded Ejaculation – males who achieve orgasm only with great difficulty or not at all • Only in partnered sexual activity • Takes longer to ejaculate or doesn’t at all • No consensus on time, but needs to be distressing

• Retrograde Ejaculation – ejaculatory fluids travel backward into bladder rather than forward • Due to effects of certain drugs or co-existing medical condition • NOT male orgasmic disorder • Premature Ejaculation – ejaculation occurs well before man and partner want it to; far more common • DSM-5 – approximately one minute after penetration • Self-identifying has three components • Behavioural – regularity of rapid ejaculation experiences • Emotional – worry/concern about ejaculating too early • Efficiency – perceiving they have little control over timing of ejaculation • Occurs primarily in inexperienced men with less education • Typically seen in young men (whereas erectile disorder is typically seen in men ages 40-64) • Only in partnered sexual activity • Ranked on severity based on time Pain Disorders • Genito-Pelvic Pain/Penetration Disorder – difficulties with penetration during attempted intercourse or significant pain during intercourse; only females • For some, sexual desire is present, and arousal and orgasm are easily attained, but pain during attempted intercourse so severe that sexual behaviour is disrupted • For some, severe anxiety or even panic attacks may occur in anticipation of possible pain during intercourse • Vaginismus – pelvic muscles in outer third wall of vagina undergo involuntary spasms when intercourse is attempted; most usual presentation of this disorder; tensing of pelvic floor muscles • May occur during any penetration (ex. gynecological exam, insertion of tampon) • Sensation of ripping, burning, tearing • Higher proportions of younger and less educated women • Not related to intercourse, but often women think it to be Biopsychosocial Factors

• Predisposing Factors – ex. lack of sexual education, over protective parents • Precipitating Factors – ex. negative first experience with sex • Perpetuating Factors – ex. repeat situation, lack of communication, lack of pleasure

• Biological • Neurological diseases and other conditions that affect nervous system (ex. diabetes, kidney disease, vascular disease) may directly interfere with sexual functioning by reducing sensitivity in genital area – common cause of erectile disorder • Vascular Disease – arterial insufficiency (constricted arteries) makes it difficult for blood to reach penis; venous leakage, makes blood flow out too quickly for erection to be maintained • Chronic Illness – who’ve had heart attacks are wary of physical exercise; coronary artery disease • Men presenting with erectile disorder should be screened for cardiovascular disease • Prescription Medicine – antihypertensive medications (ex. propranolol), selective-serotonin reuptake inhibitor (SSRI) antidepressant medications, other antidepressant and anti anxiety drugs • Sexual dysfunction is most widespread side effect of these drugs • Alcohol and other psychoactive drugs also produce sexual dysfunction • Alcohol reduces social inhibitions so people feel more like having sex (and more willing to request it), but it doesn’t facilitate sexual arousal and behaviour

• Marijuana – reports that it enhances sexual pleasure might just be psychological in that their attention is focused more completely and fully on sensory stimulation • Cigarette smoking contribute to erectile disorder

• Psychological • Environmental factors (ex. insufficient sexual context), depression, perceptions that emotional intimacy was lacking in relationship • Performance anxiety • Arousal • Cognitive Processes • Negative Affect – individuals who are dysfunctional tend to expect the worst and find the situation to be relatively negative and unpleasant • Avoid becoming aware of any sexual cues (and thus aren’t aware of how aroused they are physically, so underreporting their arousal • Distract with negative thoughts (ex. I’m going to make a fool of myself) • Women more susceptible to “appearance-based” negative thoughts • Ex. if lights are on, worry too much about how appealing my body is to my partner • Men more susceptible to “performance-based” negative thoughts • Ex. think too much about whether my partner is happy with the way I’m touching his/ her body • Ex. when man becomes anxiously aroused about ejaculating too quickly, his concern only makes the problem worse Anxiety Cycle

• Social/Cultural • Erotophobia – presumably learned in early childhood from families, religious authorities; sexuality can be negative and threatening • Sexual cues become associated with negative affect • Childhood sexual abuse – impact meanings attributed to sexually-relevant concepts (ex. bad, dirty)

• Long-lasting effects on subsequent sexual functioning • Loss of control over sexual response cycle • Marked deterioration in close interpersonal relationships • Difficult to have satisfactory sexual relationship in context of growing dislike for partner • Discomfort in telling partner what sexual activities might increase their arousal or lead to orgasm • Script Theory – we all operate according to “scripts” that reflect social and cultural expectations and guide our behaviour • Cultures with very restrictive attitudes toward sex, individuals more vulnerable to developing sexual dysfunction later in life • Vaginismus very rare in North America, but very common cause of unconsummated marriages in Ireland • India – belief that loss of semen causes depletion of physical and mental energy • Men extremely concerned about nocturnal emissions associated with erotic dreams • Devaluation of sexual experiences for females due to religious and social reasons in India • Euro-Canadian women had more sexual knowledge and experiences, liberal attitudes, and higher rates of desire, arousal, sexual receptivity, and sexual pleasure than Asian women • Anxiety from anticipated sexual activity significantly higher in Asian women • Men with dysfunction showed greater belief in sex myths (ex. good sex requires orgasm) • Socially transmitted negative attitudes about sex may interact with person’s relationship difficulties and predispositions to develop performance anxiety and, ultimately, lead to sexual dysfunction

• Treatment • Psychoeducation • Ignorance of most basic aspects of sexual response cycle and intercourse often leads to long-lasting dysfunctions • Psychological • Human Sexual Inadequacy by Masters and Johnson – male and female therapists to facilitate communication between dysfunctional partners (two week intensive program) • Sensate Focus and Nondemand Pleasuring – phases of sexual activity where partners refrain from intercourse and each phase takes a step further toward eventual intercourse and orgasm • Takes away any expectation from the anxiety they have

• By the time it’s time for intercourse, they’re ready and eager and not so focused on the anxiety surrounding it • CBT – challenging thoughts and beliefs • Communication – discuss what feels good to help each other feel satisfies • Medical • Pharmacological and surgical techniques • Viagra (and similar drugs like Levitra and Cialis) • Useful only for erectile disorder in men, not dysfunction in postmenopausal women • Oral medication, injection of vasoactive substances directly into penis, surgery, vacuum device therapy • So called “wonder drugs” – Prozac for depression; Redux for obesity • Initial overwhelming enthusiasm that drug is a cure-all, followed by period of profound disappointment as people realize drug is not really what it’s promised to be and may even be harmful in some cases; finally rationality sets in and drug becomes moderately beneficial and useful part of treatment plan • Injecting vasodilating drugs directly into penis dilate blood vessels, allowing blood to flow to penis and thereby producing erection within 15 min that can last from 1-4 hours • Side effects – bruising, fibrous nodules in penis • Penile prostheses – implanting semi-rigid silicone rod that can be bent by male into correct position for intercourse and manoeuvered out of way at other times • Often useful for men whom must have cancerous prostate removed, because this surgery often causes erectile disorder • Vacuum Device Therapy – creating vacuum in cylinder placed over penis, drawing blood into penis, which is then trapped by specially designed ring placed around base of penis • Awkward and artificial

• Assessing Sexual Behaviour • Interviews • Usually supported by numerous questionnaires because patients may provide more info on paper than in verbal interview • Interviewer must • Demonstrate through actions and interviewing style that they are comfortable talking about these issues • Use vernacular of patient, since they might not be aware of clinical terms

• Also covers nonsexual relationship issues, physical health, screens for presence of additional psychological disorders • Thorough Medical Evaluation • To rule out variety of medical conditions that can contribute to sexual problems • Some drugs prescribed for hypertension, anxiety, depression often disrupt sexual functioning • Psychophysiological Assessment • To measure directly the physiological aspects of sexual arousal • Assess abilities of individual to become sexually aroused under a variety of conditions while either awake or asleep • Penile Strain Gauge – measures penile erection directly; as penis expands, changes are recorded • Vaginal Photo-plethysmograph – inserted into vagina and measures amount of light reflected back from vaginal walls • Blood flows to vaginal walls during arousal, so amount of light passing through them decreases with increasing arousal • Nocturnal Penile Tumescence – erections occur most often during REM sleep in physically healthy men • Lack of could also be due to psychological problems (ex. depression)

• Paraphilic Disorder – sexual arousal primarily occurs in context of inappropriate objects/ individuals • Philia – strong attraction/liking • Para – indicated attraction is abnormal/atypical • Paraphilia – intense, recurrent sexual arousal manifested by atypical fantasies or behaviours; erotic activities OR erotic targets • Personal distress or impairment; personal harm or (risk of) harm to another; at least 6 months • Arousal patterns tend to be focused rather narrowly, often precluding mutually consenting adult patterns, even if they’re desired • Little to do with sexual dysfunctions except for fact that they both involve sexual behaviours, thus comprise a separate category in DSM-5 • DSM-5 – doesn’t consider a paraphilia a disorder unless it’s associated with distress or impairment or harm/threat to others

• Unusual patterns of sexual attraction aren’t considered sufficient to meet criteria for a disorder • Unusual to have just one paraphilic pattern of sexual arousal • Not uncommon to also have comorbid mood, anxiety, and substance abuse disorders • Seldom seen in women • Inability to develop adequate social relations with appropriate people for sexual relationships seems to be associated with developing inappropriate sexual outlets • Often include presence of disordered relationships during childhood and adolescence • Accidental early experience may have impact • Strong sex drive • Sexual fantasies repeatedly associated with masturbatory activities and strongly reinforced (orgasms)

• Courtship Disorders – activity preferences • Frotteuristic Disorder – recurrent and intense sexual arousal from touching or rubbing against nonconsenting person (ex. in a really crowded bus) • Voyeuristic Disorder – practice of observing unsuspecting individual undressing or naked in order to become aroused • Exhibitionist Disorder – achieving sexual arousal and gratification by exposing one’s genitals to unsuspecting strangers; compulsive or out of control behaviour

• Algolagnic Disorder – activity preferences; pain and suffering play key role in sexual interest • Sexual Sadism/Masochism Disorder – inflicting pain/punishment or humiliation (sadism) or suffering pain or humiliation (masochism) and becoming sexually aroused specifically with violence and injury • Hypoxiphilia – self-strangulation to reduce flow of oxygen to brain and enhance sensation of orgasm • For sadists, fantasies sometimes include nonconsenting partner, which causes distress to others

• Anomalous Target Preferences • Fetishistic Disorder – sexually attracted to nonliving objects • Inanimate object (ex. women’s undergarments and shoes are very popular) • Source of specific tactile stimulation (ex. rubber – clothing made out of rubber) • Partialism – part of body (ex. foot, buttocks, hair)

• Transvestic Disorder – sexual arousal is strongly associated with act of (or fantasies of) dressing in clothes of opposite sex (cross-dressing) • Males strongly inclined to dress in female clothes compensate by associating with so-called macho organizations (ex. armed forces) • If sexual arousal primarily focuses on the clothing itself, diagnostic criteria require specification “with fetishism” • Autogynephilia – thoughts or images of oneself as female • Pedophilic Disorder – sexual attraction to children (age 13 and younger) • Offender – may or may not have the disorder • Individual with disorder – may or may not have offended against a child • Ex. have child porn, but never attempted to engage in sexual activities with a child • Penile Plethysmography – used to diagnose • To be diagnosed, you must be at least 16 years of age and at least 5 years older than the child

• Assessment • Individuals may not be fully aware of what caused arousal • Ex. man only followed around women wearing open-toed sandals, but his fetish was really with women’s feet • Assess for levels of desired arousal to adults, for social skills, for ability to form relationships

• Causes

• Psychological Treatments • Covert Desensitization – sexually arousing images associated with the very consequences of the behaviour that bring the patient to treatment in the first place; entirely in imagination of patient • Immediate pleasure (strong reinforcement) more than overcomes any thoughts of possible harm/danger that might arise in future (long-term consequences) • In imagination, harmful/dangerous consequences can be associated directly with unwanted behaviour • Therapist narrates scenes dramatically for first few sessions and then instructs patient to imagine them every day until all arousal disappears • Orgasmic Reconditioning – patients instructed to masturbate to usual fantasies but substitute more desirable ones just before ejaculation • With repeated practice, they should be able to begin desired fantasy earlier in masturbatory process and retain arousal • Relapse Prevention – treatment created to addictions; patients taught to recognize early signs of temptation and to institute variety of self-control procedures before urges become too strong • Psychosocial Treatm...