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Chapter 12: Sexual Variants, Abuse, Dysfunction

“Normal” vs “Abnormal” Sexuality -

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Individual and cultural differences what is considered “normal” Criteria: o Distress o Harmful to self or others Two general categories of sexual disorders: o Sexual dysfunctions – problems with sexual responses o Paraphilic disorders – repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations

Sexual Dysfunctions -

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The person is unable to response normally in key areas of sexual functioning o As many as 31% of men and 43% of women in US suffer during their lives Typically, very distressing o Often lead to sexual frustration guilt, loss of self-esteem, and interpersonal problems o Often interrelated; many persons with one difficulty (depression) experience another (lack of sexual desire) as well 4 different types: o Lifelong – struggle with sexual dysfunction their whole lives o Acquired – normal sexual functioning preceded the disorder o Generalized – present during all sexual situations o Situational – tied to specific situations The human response can be described as a cycle with 4 phases: o Desire o Excitement/Arousal o Orgasm o Resolution (or refractory period) Sexual dysfunctions affect one or more of the first three phases

Disorders of Desire -

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Desire phase of the sexual response cycle o Consists of an interest in or urge to have sex, sexual fantasies, and sexual attraction to others Disorders involve lack of interest in sex and little initiation of sexual activity o DSM-5 combines “female sexual interest/arousal disorder” into one diagnostic category 17% of men (male hypoactive sexual desire disorder) 20-30% of sexually active women; 44% post-menopausal

Biological causes: -

Several hormones interact to produce sexual desire and behavior

Abnormalities in their activity can lower sex drive  Include prolactin, testosterone, and estrogen for both men and women o Helps explain the age-related increase in these disorders May also be linked to high levels of serotonin and dopamine Sex drive can also be lowered by some medications (such as birth control and pain meds), some psychotropic drugs (especially SSRI anti-depressants), some illegal drugs, and chronic illness o

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Psychological causes: -

A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women Certain psychological disorders, included depression and OCD, may lead to sexual desire disorders Poor body image, low self-esteem Fears, attitudes, and memories may contribute to sexual dysfunction o The trauma of sexual molestation or assault is especially likely to produce sexual dysfunction

Sociocultural (and other contextual) causes: -

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Attitudes, fears, and psychological disorders that contribute to sexual desire disorders occur within a social context o Many sufferers of desire disorders are feeling situational pressures  Divorce, death, job stress, infertility or relationship difficulties Cultural standards can set the stage for development of these disorders Religious beliefs

Specific Interventions for Disorders of Sexual Desire -

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Among the most difficult to treat because of the many issues that feed into them. Also, very little research Therapists typically apply a combination of techniques, which may include: o Emotional awareness, CBT, self-instruction training, behavioral techniques, insightoriented therapy, sensate focus exercises Biological intervention such as hormone treatments (primarily testosterone), bupropion (antidepressant). FDA approved drug for women, Addyi, to increase desire

Disorders of Excitement/Arousal -

Subjective experience of sexual pleasure Marked by changes in the pelvic region, general physical arousal, and increase heart rate, muscle tension, blood pressure, and rate of breathing o In men: erection of the penis o In women; swelling of the clitoris and vatical lubrication

Essentials for Good Sex... -

Two F’s

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Fantasy  Erotic thoughts  Facilitated by romance, intimacy, play. Flirtation, non-genital touch Friction  Stimulation of genitals and other erogenous body parts  Penis clitoris  Nipples, anus, perineum, scrotum

Disorders of Excitement/Arousal -

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Erectile disorder (ED) o Characterized by inability to attain or maintain an erecting during sexual activity; or reduced erectile rigidity o 7% ages 18-19; 18% in ages 50-59, up to 90% for those taking SSRIs o According to surveys, half of all adult men have ED during intercourse at least some of the time Female sexual arousal disorder o Absence of vaginal lubrication o May occur in up to 30% of women (as combined desire/arousal disorder)  Rates increase post-menopause – 44%

Biological causes: -

The same hormonal imbalance that can cause male hypoactive sexual desire can produce Ed Most commonly, vascular problems are involved o ED can also be caused by damage to the nervous system from various diseases, disorders, or injuries o Differential diagnosis: Assessing nocturnal penile tumescence  Men typically have erections during REM sleep  Abnormal or absent nighttime erecting usually indicate a physical basis for erectile failure o The use of certain medications and various forms of substance abuse may interfere with erections

Psychological causes: -

Any of the psychological causes on inhibited sexual desire can also interfere with sexual arousal Performance anxiety and the spectator role o Once a person begins to have arousal (or orgasmic) difficulties, they become fearful and worry during future sexual encounters  Instead of being participant, they become a spectator and a judge  This can create a vicious cycle of sexual dysfunction where the original cause of the sexual difficulties become less important than the fear of failure

Psychosocial interventions:

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Psychoeducation: about sexual anatomy, sexual arousal and stimulation, and sources of inhibition Reducing performance anxiety and increasing effective stimulation o Sensate focus exercises: progressive, nondemanding sensual  sexual pleasuring o Cognitive restructuring: “lowering the stakes” Behavioral rehearsal: Acquiring proprioceptive awareness o Learning “what turns you (or your partner) on”

Disorders of Orgasm -

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Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically o For men: semen in ejaculated o For women: the outer third of the vaginal walls contract There are 3 disorders in this phase: o Early ejaculation o Delayed ejaculation o Female orgasmic disorder

Early ejaculation: -

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Persistent reaching of orgasm and ejaculation within one minute of penetration o As many as 30% of men experience rapid ejaculation at some time The dysfunction seems to be typical of young men (inexperienced and/or following period of abstinence) Psychological explanation of this disorder has received more research support than other explanations o Anxiety, hurried masturbation experiences, or poor recognition of arousal Biological factor: men with this dysfunction may have greater sensitivity in the area of their penis; higher levels of arousal to sexual stimuli Treatments include behavioral procedures such as the “stop-start,” “pause,” or “squeeze” techniques and medications such as SSRIs

Delayed ejaculation: -

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Repeated inability to ejaculate or very delayed ejaculation after normal sexual activity with a partner o Occurs in 3-10% of the male population A leading psychological cause appears to be performance anxiety and the spectator role Biological causes include low testosterone, neurological disease, and head or spinal cord injury o Medications, including certain antidepressants (especially SSRIs) Treatments: o Reduce performance anxiety  Shifts focus of “success” away from orgasm to intimacy o Increase stimulation (arousal) o Couples therapy

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Increase association between orgasm and intercourse (vs orgasm and masturbation)

Female Orgasmic Disorder: -

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Persistent failure to reach orgasm, experiencing orgasms of very low intensity, or delay in orgasm o Roughly 33% of women appear to have this problem (last year) o Most common in ages 21-21  10% or more have never reached orgasm  9% reach orgasm rarely Women who are more sexually assertive and comfortable with masturbation have orgasm smore regularly Many clinicians argue that orgasm during intercourse is not mandatory for “normal” sexual functioning o LJO: There’s no reason for women to accept or resign themselves to the persistent absence of orgasms during sex Treatment: o Distinguish between lifelong vs. situational o Specific treatments include CBT, self-exploration, enhancement of body awareness, and directed masturbation training

Disorders of Sexual Pain -

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Genito-pelvic pain/ penetration disorder Characterized by significant pain during intercourse or penetration attempts; tensing or tightening of pelvic floor muscle during attempted penetration; fear or anxiety about pain prior to or during penetration o Muscle tension can prevent penetration Biological (disease, structural) causes should be ruled out o E.g., inflammation, infection, vaginal atrophy (age related), scarring from vaginal tearing Treated with psychoeducation, progressive relaxation, vaginal dilator

Paraphilic Disorders -

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Recurrent, intense sexual arousing fantasies, sexual urges, or behaviors that generally involve: o Abnormal targets of sexual attraction o Unusual courtship of behaviors o Desire for pain and suffering of oneself or others Paraphilia o Unusual sexual interests o Need not cause harm either to the individual or others Paraphilic Disorder o Unusual sexual interests o Cause significant distress or impairment AND/OR o Cause harm to self or others

Paraphilias:

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Fetishism: o Arousal from nonliving objects (e.g., pantyhose) or non-erogenous body parts (e.g., feet) Transvestic fetishism: o Arousal from cross-dressing o Auto-gynephilia = arousal by the thought/fantasy of being a woman o Majority are heterosexual (87%) and married Pedophilia: o Arousing fantasies, urges, or behaviors involving sexual activity with prepubescent child(ren) (13 or younger) o Hebephilia = pubescent children (in early stages of puberty) – not in DSM-5 Voyeurism (aka “Peeping Tom”): o Arousal from observing an unsuspecting person who is naked, undressing, or engaging in sexual activities Exhibitionism: o Arousal from the exposure of one’s genital to an unsuspecting person w/o their consent Frotteurism: o Arousal from touching or rubbing against a nonconsenting person Sexual sadism: o Arousal from the physical or psychological suffering of another o Serial killers Sexual masochism: o Arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer o Autoerotic asphyxia

Causes of Paraphilic Disorders Causal factors: -

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Male gender Paraphilia usually begins at puberty Strong sex drive o Frequent masturbation (numerous times daily) o High rates of pornography use Multiple paraphilias o Likely to have more than 1 Dependence on visual sexual imagery for males (vs. females) o Classical conditioning; modeling

Gender Dysphoria – Definitions -

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Sexual orientation: enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both o Can also refer to a person’s sense of identity based on those attractions. Continuum – heterosexual, bisexual, homosexual Biological sex: anatomical, physiological, genetic characteristics of being male or female Gender identity: psychological sense of being male or female

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Social gender role: cultural norms that define feminine and masculine behavior

Gender Dysphoria – Children -

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Discomfort with assigned gender or sex relevant physical characteristics o Degree of dysphoria can vary and may fluctuate over time within the same individual o Diagnosis can occur during childhood or adolescence/adulthood Criteria: o Strong desire to be of the opposite gender o In boys, preference for female attires; in girls, preference for wearing masculine clothing, strong resistance to wearing typical female clothing o Strong reference for cross-gender roles during play/fantasies o Strong preference for toys, games, activities stereotypically used by other gender o Strong preference for playmates of other genders o In boys, strong rejection of typically masculine activities (rough & tumble play); in girls, rejection of stereotypical female activities o Strong dislike of one’s sexual anatomy o Strong desire for the primary and/or secondary sex characteristic that match one’s experience gender Boys: o Present for treatment 3-5x more* o Adult outcome: homosexuality (rather than transsexualism) Girls: o Tend to be treated better by peers o Adult outcome: less clear, may lead to homosexuality but only small studies done Treatment: o Discrepancy between biological sex & psychological gender o Depression & anxiety o Hormone treatments

Many such children typically adjust well in adulthood; most do not become adults with gender dysphoria Gender Dysphoria – Adults -

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Transsexualism = occurs in adults with gender dysphoria (usually since childhood) who want to change their sex o Capture the majority of female to male transsexuals Homosexual transsexuals o Feminine men attracted to men o “Woman trapped in a man’s body” Autogynephilic transsexuals o Paraphilia characterized by man’s sexual arousal at thought of being woman  Most report history of transvestic fetishism but also fantasize about having female genitalia o Differ from homosexual transsexual:  Have more fetishistic and masochistic tendencies

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Stronger preference for younger and more attractive partners Stronger interest in uncommitted sex

Treatment for Transsexualism -

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Psychotherapy: o Not effective for resolving gender dysphoria o Is beneficial to treat secondary anxiety or depression Only effective treatment is gender affirming surgery (aka sex reassignment): o Step 1: hormone treatments  Men are given estrogens to facilitate breast growth, skin softening, shrinking of muscles  Women are given testosterone to suppress menstruation, increase facial and body hair, deepen the voice  Must live for many months with hormonal therapy before eligible for surgery o Step 2: surgery  Men: removal of penis and testes, creation of an artificial vagina (often functional)  Women: mastectomies and hysterectomies; plastic surgery to alter facial features; some seek artificial penis (non-functional) o Treatment is generally quite successful  Happy with their decisions, happy with surgery outcomes

Sexual Abuse -

Pedophilia Incest Rape

Childhood Sexual Abuse -

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Prevalence is 4-6% in US Abuse frequently involves manual or oral contact; penetrative sex is less common Consequences: o 2x likely to develop mental health disorder o At higher risk for fear/anxiety and substance abuse disorders, suicidal behaviors  Recall the risk factors we’ve discussed for nearly every disorder o Sexually-related symptoms – sexual aversion or sexual promiscuity Controversies: o Children’s testimony and recovered memories of sexual abuse Perpetrators meet criteria for Pedophilic Disorder (already discussed)

Incest -

Culturally prohibited sexual relations between family members Prevalence difficult to estimate because it is often unreported Majority of incest offenses are against girls

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o Brother-sister is most common; father-daughter is second Some perpetrators have pedophilic arousal tendencies but not all offenses are against children

Rape -

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Sexual intercourse or penetration involving the actual or threatened forcible coercion of one person by another Statutory rape is sexual activity with person under the age of consent (18 in most states) even if the individual consents Sexual assault refers to stages Prevalence: o 5-13% depending on definition o Rapist often known to victim (78% of the cases) o Risk highest in women under age 34 (especially those in low-income & rural areas) Potential consequences: o Physical trauma o Psychological trauma  PTSD  Anxiety  Depression  Anger  Diminished self-image  Self-blame Characteristics of rapists: o Tend to be younger (under the age of 25) o Of rapists in police records, 30-50% are married & living with wife at the time of the crime o Low SES o Prior criminal record o Childhood: likely to have experienced sexual abuse; violent environment; inconsistent parenting o Personality: impulsive, quick loss of temper, lack of personally intimate relationships, insensitivity to social cue or pressures Date rapists: o Rape individual within the context of a date or other social interaction (e.g., part) o Middle to upper-class SES o Rarely have criminal records o Victims are generally highly intoxicated; sometimes drugged (e.g., Rohypnol) o Like incarcerated rapists, demonstrate promiscuity, hostile masculinity emotionally detached, predatory personality

Is rape motivated by sex or aggression? -

Regardless of motivation, always an act of violence Rapists usually cite sexual motivation as an important cause of their actions

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Researchers indicate rapists have both sexual and aggressive motives though to varying degrees

Treatment of Sex Offenders -

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Research shows outcomes are 1) mixed; 2) controversial o Hard to study due to small sample sizes – few rapes are reported, fewer are convicted o Some studies show no differences; others show treatment is helpful Primary goal of treatment is to stop future sexual offenses o Recidivism = tendency of criminal to reoffend What we know: o High rates of recidivism among offenders with deviant sexual preferences (e.g., exhibitionism, severe sadism, pedophilia) o Strongest predictor of reoffending = preference for sadist or coercive sex o Other predictors: negative social influences, poor cognitive problem solving, loneliness o Recidivism rates for rape and sexually deviant behavior decrease with age  Reduced sexual desire and activity Psychological treatments: o Aversion therapy o Covert sensitization/ assisted covert sensitization o Cognitive restructuring o Social-skills training o Most effective models follow “Risk-Need-Responsiveness” model Biological treatments: o Biological and surgical  Castration (surgical or chemical/hormonal) o Hormone therapy and cognitive-behavioral combination...