CPch12 - Sexual Disorders Flashcards
(90 cards)
1
Q
how has the definition of what is normal or desirable in human sexual behavior varied in time and place?
A
- now inhibition of sexual expression is a problem
- 19th and 20th century: excess is a problem
> too much masturbation would lead to sexual dysfunctions in adulthood - Kellogg’s Corn Flakes were developed as foods that would lessen sexual interest
- 1970s access to birth control pill
- 1980s AIDS epidemic
- 1990s access to sexual content on the internet
2
Q
What are the differences across cultures regarding the expression of sexual orientation?
A
- concealment is a function of social and political factors
- minorities still discriminated mostly in African and Middle Eastern Countries
> face imprisonment, blackmail, sexual assault, not legal recourse, … - in some cultures sexuality seen as part of well-being and pleasure, in others just as procreation
- DSM diagnosis for homosexuality until 1973
- (look at table)
3
Q
Gender Dysphoria
- why is it a controversial diagnosis?
A
- present in DSM but highly debated
> cross-gender behavior is universal (animals engage in opposite sex’s behaviors and children play above gender)
> existence of diagnosis implicitly indicates need for treatment
> diagnosing gender nonconformity might foster more stigma - 90% of people with gender reassigning surgery do not regret it * better life satisfaction, mental health, sexual satisfaction, partner relation…
4
Q
Research methods in sexuality studies
A
- Masters and Johnson (1966)
> direct observation and physiological measurements of people masturbating or having sexual intercourse + frank discussion + attention to biological processes
> penile or vaginal plethysmograph to measure arousal (blood flow to genitals)
5
Q
what are the gender differences in sexuality?
A
- common misconception: women have sex for relationship closeness (in reality reported having sex for attraction and physical gratification)
- less gender differences in cultures with more empowering attitudes towards women
- men still engage in more masturbation and more pornography
6
Q
Is this gender difference genuine, or could it reflect disclosure patterns?
A
- study: questionnaire administered to men and women, one condition with fake lie detector
- in condition with lie detector, women reported same rate of pornography and masturbation as men
= gender differences may be biased by attempt to match cultural expectations
7
Q
subjective vs biological arousal in men and women
A
- interest and subjective arousal often co-occur for women
- women’s sexual interest often follows (rather than precedes) their biological arousal
- subjective arousal may not mirror biological arousal for women, but it does for men
> women experience rapid, automatic response to sexual stimuli of both genders, while men only when sexual stimuli of preferred gender - amount of blood flow to the vagina has little correlation with women’s subjective level of desire or arousal (e.g. report of little or no subjective arousal when biological arousal occurs)
8
Q
Sexual Interest
A
sexual desire, often associated with sexually arousing fantasies or thoughts
9
Q
Subjective arousal
A
self-perception of sexual excitement
10
Q
Biological arousal
A
changes in blood flow to genitalia, which can be measured by penile or vaginal plethysmography
11
Q
Orgasm
A
Ejaculation in men, contraction of the outer walls of the vagina in women
12
Q
Resolution
A
post-orgasm phase
(for men further erection is not possible during a refractory period)
13
Q
what are the three categories of sexual dysfunctions?
what disorders are there in each category?
A
- involving sexual desire, arousal and interest
> female sexual interest/arousal disorder (F)
> male hypoactive sexual desire disorder (M)
> erectile disorder (M) - orgasmic disorders
> female orgasmic disorder (F)
> premature ejaculation (M)
> delayed ejaculation (M) - involving sexual pain
> genito-pelvic pain/penetration disorder (F)
14
Q
what are general criteria for all sexual dysfunction disorders?
A
- dysfunction should be persistent and recurrent
- dysfunction should cause clinically significant distress
- at least present for six months
! diagnosis not appropriate if dysfunction is due to medical illness (e.g. diabetes) or psychological disorder (e.g. MDD)
15
Q
Reporting of sexual dysfunctions
A
- one sexual dysfunction might lead to other s.d.
- sexual dysfunction disorder in one partner might lead to other partner developing sexual problems
- sexual distress due to severe relationship distress should not be regarder as disorder
16
Q
Prevalence of sexual dysfunctions
A
(see photo)
17
Q
Overview of disorders involving sexual interest, desire and arousal
A
- most subjective
- often partner will encourage other partner to look for clinician
- some disorders might be due to expectations about how much sex a person should want
- age might also influence expectations
- DSM-5 criteria for sexual interest/arousal disorder in women include biologically or subjectively low arousal or desire (more concern over lack of subjective than biological arousal)
18
Q
Female sexual interest/arousal disorder
+ criteria
A
“Persistent deficits in sexual interest, biological arousal or subjective arousal”
* Diminished, absent or reduced frequency of at least three of the following:
- interest in sexual activity
- erotic thoughts or fantasies
- initiation of sexual activity and 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 causes
- genital or nongenital sensations during 75% of sexual encounters
19
Q
Male hypoactive sexual desire disorder
A
“Deficient or absent sexual fantasies and urges”
* on at least 75% of occasions:
- inability to attain an erection (or)
- inability to maintain an ereciton for completion of sexual activity (or)
- marked decrease in erectile rigidity that interferes with penetration or pleasure
20
Q
Erectile disorder
A
“failure to attain or maintain an erection through completion of sexual activity”
- problem is physical arousal, not subjective
- prevalence increases sharply with age (50% of men >60 report erectile dysfunction)
21
Q
Orgasmic Disorders
A
22
Q
Female orgasmic disorder
A
“persistent absence or reduced intensity of orgasm after sexual excitement”
* on at least 75% of sexual occasions:
- marked delay, infrequency or absence or orgasm (or)
- markedly reduced intensity of orgasmic sensation
23
Q
facts about female orgasm
A
- women more orgasms with age (learn more about their bodies and sexual needs overtime)
- orgasm threshold different among women
- more likely to have orgasm in close relationships
- emotional closeness more important than achieving orgasm (for women)
- 2/3 have faked orgasm not to upset partner
- arousal levels while viewing erotic stimuli do not differ in women with or without orgasmic disorder
24
Q
Premature ejaculation disorder
A
“ejaculation that occurs too quickly”
- tendency to ejaculate during partnered sexual activity within 1 minute of penile insertion on at least 75% of sexual occasions
> median time to ejaculation is 5 minutes after penis instertion
25
Delayed ejaculation disorder
"persistent difficulty in ejaculating"
- marked delay, infrequency or absence or orgasm on at least 75% or partenered sexual occasions
> least common sexual dysfunction among men
> mostly reported happening during intercourse but not masturbation
26
Sexual Pain Disorder
- Genito-pelvic pain/penetration disorder
- persistent or recurrent pain during intercourse
- often experience vaginismus (involuntary muscle spasms of the outer third of the vagina - makes intercourse impossible)
- to diagnose, make sure that not due to infection or lack of vaginal lubrification
- normal experience of arousal and can reach orgasm by oral or manual stimulation
! 50% of female participants experience pain during intercourse
! 50% of women experiencing pain do not regard it as a problem
27
what are the criteria for GPP/PD?
persistent or recurrent difficulties with at least one of the following:
- inability to have vaginal penetration during intercourse
- marked vulvar, vaginal or pelvic pain during vaginal penetration or intercourse attempts
- marked fear or anxiety about pain or penetration
- marked tensing of the pelvic floor muscles during attempted vaignal penetration
28
Etiology of sexual dysfunctions
- Biological influences
(smoking, drinking, cardiovascular disease, diabetes, neurological disease, hormone dysfunction, SSRI medication, other medical illnesses or medications)
- Social influences
(rape or sexual abuse, no education on sexuality, relationship difficulties, negative cultural attitudes towards sexuality)
- psychological influences
(depression and anxiety, low physiological arousal/exhaustion; negative cognitions about sex, appearance, sexual performance; guilt and self blame)
!! often correlated
29
Biological Influences
- first step is to rule out medical disease as the cause
- diabetes, multiple sclerosis, spinal cord injury, heavy alcohol use before sex, chronic alcohol use, heavy cigarette smoking, ...
- in men: low levels of testosterone or high levels of steroids and testosterone supplements
- SSRIs and antidepressants can lead to interest and orgasmic disorders
30
What are some biological explanations to specific sexual disorders?
- erectile disorder: vascular disorder (not enough blood to penis)
- premature ejaculation disorder: SSRIs (abnormal serotonin receptors)
- GPP/PD: neurologically based supersensitivity to pain
- low interest/arousal disorder: low estradiol or testosterone levels
31
Psychosocial influences
- rape, sexual abuse or absence of positive sexual experiences
- childhood sexual abuse: diminished arousal and desire, higher rates of genital pain, double rate or premature ejaculation
- relationship problems (specifically concerns about partner's affection - F)
- poor communication around sex with partner (especially F)
- negative cognitions (...)
32
what are the physiological influences?
- depression (3 times more likely to report SD) and anxiety (2 times)
> depression and anxiety comorbid with sexual pain, lack of sexual desire or arousal, female orgasmic disorder
- low general physiological arousal
> when exhausted-> lower arousal
33
Negative cognitions
-worries about pregnancy, sexual performance, AIDS, ...
- negative attitudes towards sex
- worries about weight and appearance (F)
- self-blame for poor performance
- negative views on sexuality learnt through social and cultural surrounding (religion, communities, ...)
34
the role of self-blame
(+ study)
- variability in sexual performance is common depending on context, stressors, concerns...
- people who blame themselves for decreased sexual performance are more likely to develop sexual problems
- (study) men watched arousing movie and were tested with penile plethysmograph
> then were told that erection was smaller then average
> two conditions (one internal explanation, the other external explanation
> ones with internal explanation showed lower subjective and biological arousal when second movie
35
Treatments of Sexual Dysfunctions
(general characteristics)
- only a third seek professional help
- multimodal treament is necessary because the causes are many
- first, always adress biological factors if present
- as Christos suggested, the red light district
36
Psychoeducation
- provide information about how common sexual dysfunctions are and their sources
- this reduces anxiety, normalizes concern, eliminate blame, better communication, ...
- written material and videos to help clients understand more about body and sexual techniques
37
Couples therapy
- training in nonsexual communication skills
- interventions not only on sex, but also about relationship in general
- suggestion to plan romantic events to restore closeness and intimacy
- encouragement to communicate sexual likes and dislikes to each other
38
Cognitive Interventions
- challenge self-demanding and perfectionistic thoughts that cause problems
- e.g. challenge idea that intercourse is only form of sexual activity for men with erectile dysfunction
- e.g. help women limit appearance and weight concerns and view differently their bodies and sexuality
39
Sensate Focus
- by Masters and Johnson
- no intercourse or touching during sensate-focus exercises
- one partner slowly undresses the other and touches him/her, then roles switch
- promotes contact and realization that sexual encounters do not have to start by intercourse
- against destructive tendency to think about one's performance or attractiveness during sex
- more constructive communication of sexual preferences
40
Treatments for specific sexual dysfunctions in women
- Female sexual interest/arousal disorder: Flibanserin (Addyi)
> not very effective and many side effects
- Female Orgasmic Disorder: directed masturbation
- GPP/PD: training in relaxation, practice with inserting fingers or dilators (gradual)
41
how does directed masturbation work?
- to enhance women's comfort with and enjoyment of their sexuality
1. woman examines her genitals with aid of diagrams
2. touch her genital to identify pleasurable areas
3. increase intensity with erotic fantasies
4. if no orgasm, then vibrator
5. partner joins in, observes woman while masturbating, does for her same movements, have intercourse to stimulate same parts
- 60-90% of women achieve orgasm afterwards
42
Treatments for specific sexual dysfunctions in men
- premature ejaculation: SSRIs (to be taken an hour before sex)
> squeeze technique (squeeze penis in area where head and shaft meet to reduce arousal)
> withdrawal of penis during penetration
> psycotherapy
- erectile disorder: phosphodiesterase type 5 (PDS-5) inhibitor (e.g. viagra, cialia, levitra, ...) - they relax smooth muscles and create erection upon stimulation; side effects of headaches and indigestion
> sex therapy
43
Paraphilic disorders
(general overview)
- recurrent sexual attraction to unusual objects or activities
- lasts at least 6 months
- categories based on the sources of arousal
- many people occasionally fantasize about this kind of activities and engage in behaviors
- distress, impairment and engagement of nonconsenting others distinguish normal and problematic sexual behavior
- not every disorder involves nonconsenting others (e.g. transvestic and fetishistic disorder only distress)
- prevalence is hard to determine
- mostly heterosexual men
- onset begins in adolescence
- often comorbid with each other
44
List of paraphilic disorders in DSM-V
+ object of sexual attraction
- fetishistic disorder (an inanimate object or nongenital body part)
- transvestic disorder (cross-dressing)
- pedophilic disorder (children)
- voyeuristic disorder (watching unsuspecting others undress or have sex)
- exhibistionistic disorder (exposing one's genitalia to an unwilling stranger)
- frotteuristic disorder (sexual touching of an unsuspecting person)
- sexual sadism disorder (inflicting pain)
- sexual masochism disorder (receiving pain)
45
Pedophilic Disorder - criteria
- for at least 6 months
- recurrent and intense sexually arousing fantasies, urges or behaviors involving sexual contact with a prepubescent child
- person has acted on these urges or the urges and fantasies cause marked distress or interpersonal problems
- peson is at least 16 years old and 5 years older than the child
46
Pedophilic Disorder - characteristics
- stroking a child's hair
- manipulating child's genitalia or encouraging child to manipulate his
- penile insertion
> molestation repeated for weeks, months or years
> often no violence
> mostly heterosexual men (half of convicted are not married)
47
Pedophilic disorder - sexual arousal
- sexual arousal measured through penile plethysmograph (one of strongest predictors of repeated sexual offenses)
- 1/4 men showed biological arousal when seeing provocative pictures of children, but no subjective arousal
> difference is in relative arousal: people with pedophilic disorder showed more arousal for children than for adults, opposite to people with conventional interests
48
Incest
- subtype of pedophilic disorder
- sexual relations between family members whose marriage is forbidden
- most common between brother and sister, then father and post-puberty daughter
- taboo is evolutionary (offspring of incest has increased risk or recessive genes -> birth defects)
49
Voyeuristic disorder - criteria
- at least 6 months
- recurrent and intense sexually arousing fantasies, urges or behaviors involving the observation of unsuspecting others who are naked, undressing or engaging in sexual activity
- person has acted on urges with nonconsenting person, or urges and fantasies cause marked distress or interpersonal problems
50
Voyeuristic disorder - characteristics
- fantasies are quite common in men (not enough for diagnosis)
- orgasm through masturbation while watching or remembering the scene
- element of risk and threat of discovery are important
51
Exhibitionistic Disorder - criteria
- at least 6 months
- recurrent, intense and sexually arousing fantasies, urges or behaviours involving showing one's genitals to an unsuspecting person
- person has acted on these urges towards a nonconsenting person, or the urges and fantasies cause clinically significant distress or interpersonal problems
52
Exhibitionistic Disorder - characteristics
- seldom attempt to have contact with stranger
- often masturbate during exposure
- desire to shock or embarass observer
- arrest for 1/150 occurances
53
Frotteuristic Disorder - criteria
- at least 6 months
- recurrent and intense sexually aruosing fantasies, urges, or behaviours involving touching or rubbing against a nonconsenting person
- person has acted on these urges with a nonconsenting person, or the urges and fantasies cause clinically significant distress or problems
54
Frotteuristic Disorder - characteristics
- mostly in crowded places (busses or sidewalks)
- report engaging in behaviors dozens of times
- may rub penis against woman's thighs or butt or fondle breasts or genitals
55
Sexual Sadism Disorder - criteria
- at least six months
- recurrent, intense and sexually arousing fantasies, urges or behaviours involving the physical or psychological suffering of another person
- causes marked distress or impairment in functioning or the person has acted on these urges with a nonconsenting person
56
Sexual masochism disorder - criteria
- at least six months
- recurrent, intense and sexually arousing fantasies, urges or behaviours involving the act of being humiliated, beaten, bound or made to suffer
- causes marked distress or impairment in functioning
57
Sadomasochism - general characteristics
- physical bondage, blindfolding, spanking, whipping, electric shocks, cutting, humiliation (e.g. being defecated on), taking role of slave and submitting to orders and commands
- sadists establish relationships with masochists to gain mutual gratification
- more masochists than sadists
- often not distress -> no diagnosis
58
why are sadomasochistic disorders in the DSM-V?
- certain practices can be dangerous
> e.g. "asphyxiophilia": sexual arousal by restricting breathing (plastic bag or chest compression; can result in death)
59
# Etiology
Etiology of Paraphilic disorders
- neurobiological influences, childhood sexual abuse, psychological influences
- many gaps in knowledge about why some people are not able to control interests and become disorder
- problem of small sample sizes
- most research on cases that led to arrest
60
# Etiology
Neurobiological Influences
- most people with paraphilic disorders are men, so there was the hypothesis that androgens (e.g. testosterone) play a role in disorders
- no higher levels of testosterone if disorder -> hypothesis debunked
61
# Etiology
Childhood Sexual abuse
- 40-66% of sexual offenders reported history of sexual abuse
= sexual abuse is tied to sexual offending
- (study) fewer than 5% of sexually abused boys were charged with any type of sexual offense
62
Overview of Childhood Sexual Abuse (CSA)
- 10% of adults reported some sort of CSA (girls three times more than boys)
- child abuser usually not a stranger
- trust is important factor
- sexual gender-based violence (SGBV) increased during covid (more internet and no protective factors)
- consequences on long-term mental health and sexual and reproductive health
63
Effects of CSA - children
- depression, low self-esteem, conduct disorder, anxiety disorders, or PTSD
> often symptoms not exhibited for a while
> symptoms more pronounced if involve sexual intercourse or violence or when start earlier age
> usually linked to other disorders in family or environmental factors
> very hard for child to report CSA + often no evidence
64
Effects of CSA - adults
- dissociative identity disorder, PTSD, eating disorders, borderline personality disorder, major depressive disorder, and substance use disorder
- lower self-esteem, less life satisfaction, poorer romantic relationships, and greater risk of sexual dysfunctions
- (study) adults with history of CSA: higher risk of depression, suicide, conduct disorder, alcohol use disorder, social anxiety, rape, and divorce than their nonabused twins
65
# Etiology
Psychological Influences
- sexual activity used to escape negative affect
- longer-term problems with emotion regulation
- many occasions of exhibitionistic, voyeuristic and pedophilic disorder happen under effect of alcohol (action is result of impulse)
> also higher impulsivity in personality
- when involving nonconsenting women or children, sexual behavior might stem from hostile attitudes and lack of empathy towards target
66
# Etiology
why don't most of people with pedophilic disorder engage in action?
- ability to infer another person's emotional state could help protect against acting on pedophilic urges
- (study) men who acted on pedophilic urges were less able to judge children's emotional expressions (lack of empathy)
67
# Etiology
pedophilic disorder - associations and pathways
* associated with pedophilia:
> neurocognitive problems and lower IQ
> minor physical anomalies (atypical prenatal development)
* different pathways:
> some show intense preoccupation with sex, sense of emotional compatibility with children and specific sexual preference
> others show elevated impulsivity and psychopathy
68
# Treatments
Treatments for paraphilic disorders
- why so few evidence?
- motivational, cognitive behavioral, hormone and SSRI treatments
1. treatment research focused on people in jail
2. small amounts of long-term data available
3. most studies have not randomly assigned participants to conditions (unethical)
> no RCTs available to consider efficacy of SSRIs for paraphilic disorders
69
# Treatments
What have the RCTs shown about efficacy of treatments?
- CBT: no significant effects on legal recidivism (relapse into criminal behavior)
- hormone agents reduce arousal, but not much evidence that medication reduces sexual offending (+ high dropout rates)
70
# Treatments
strategies to enhance motivation
- sex offenders often no motivation to reduce illegal behavior (deny and minimize problem)
- to increase motivation: increase client's hope to regain control of urges and behavior
- help client focus on reasons for change (legal and other)
71
# Treatments
Aversion therapy (CBT)
- association of urge with aversive stimulus
> e.g. shock or induced nausea when looking at picture of naked child in pedophilic disorder
> "satiation": masturbating for 55 minutes after orgasm
> "covert sensitization": imagine negative consequences of inappropriate sexual behavior
72
# Treatments
Cognitive interventions
- to challenge distorted views
> e.g. thinking that girls exposed to genitals are too young to be harmed by it (exhibitionistic disorder)
> exposure to idea that younger victims-> more harm
- social skills training, sexual impulse control strategies, empathy training and relapse prevention
73
# Treatments
Biological Treatments
- hormonal agents to reduce androgens
> medroxyprogesterone acetate (MPA)
> cyproterone acetate (CPA)
- not much efficacy and many side effects
> feminization, infertility, liver problems, osteoporosis, diabetes, and depression
74
Prevention
- treatment for paraphilias often takes place after offense
- programs to reach out for help before committing crime (with CBT and medication)
> apparent changes in cognition about victims and perceived ability to regulate urges
> 5/25 people that engaged in sexual abuse before treatment, maintained it afterwards
75
Protection of the public vs Civil liberties of people with paraphilias
- usually cannot detain person for possibility of future sexual offense
- "person deemed at high risk for a sex crime can be detained if the risk is related to a psychological disorder that diminishes the person’s ability to control his or her sexual behavior" (USA)
- Megan's law: police is authorized to release whereabouts of sex offender
> sometimes led to more crimes towards sex offender
! big debate overall
76
General information about Rape
- "attempted or completed vaginal, anal, or oral sexual intercourse obtained through force, through the threat of force, or when the victim is incapacitated and unable to give consent"
- more women than men raped, but estimation of 96% of male raped unreported
- sexual assault rose from 183% to 299% (2006 - 2016)
- 6.7 to 60% reported having experienced coercive behavior
- sexual violence reflects social and cultural problem
- usually from: partner, no suspect, family, stranger, other known person (in order)
77
# slides
Slides - general information
- young people give their sex life an average of 7
- 8/10 enjoy sex very much
- 9/10 felt fine during sex with their last sex partner
78
# slides
Orgasm Frequency
(see photo)
79
# slides
How often do couples have sex?
(previous week)
- 25%: 0 times
- 12%: 2 times
! 0,1% ends up in conception
80
# slides
Why do humans have sex?
- physical reasons (stress reduction, pleasure, physical desirability, experience seeking)
- goal attainment (resources, social status, revenge, utilitarian)
- emotions (love, commitment, expression)
- insecurity (self-esteem boost, duty/pressure, mate guarding)
81
# slides
What are the trends of "firsts"?
(time and gender)
(see photo)
82
# slides
what are the percentages of people not exclusively heterosexual? (NL)
- girls: 1/4
- boys: 1/9
(generational shift)
83
# slides
pleasurable penetration:
men vs women
- penis and clitoris have same size and same origin
- pleasurable penetration:
> men: erection and rigidity
> women: swelling and humidity (lubrication)
> both due to vasocongestion (increased blood flow)
84
# slides
Sexual response cycle
1. desire phase
> sexual interest associated with arousing fantasies or thoughts
2. excitement phase
> increased blood flow to genitalia
3. orgasm phase
> sexual pleasure peaks
4. resolution phase
> relaxation and sense of well-being following an orgasm
85
# slides
Sex vs eating association
- craving, opportunity, love, experience, negative reinforcement, exchange
- sex is not in physiological needs in Maslow's hierarchy, but can be compared to eating in desire/craving
- stimulus vs goal based
86
# slides
Social exchange theory
- rewards and costs (e.g. sex for love, love for sex and sex for money)
- equity, matching hypothesis
87
# slides
Sexual problems - categories
- acquired vs lifelong
- situational vs generalized
88
# slides
What is the correlation between subjective and physiological arousal?
men vs women
- men: .66
- women: .29
89
# slides
Successful sexual functioning
(characteristics)
- psychological factors
> good emotional health, attraction and positive attitude towards partner, positive sexual attitude
- physical factors
> good physical health, regular appropriate exercise, good nutrition
- social and sexual history factors
> positive sexual experiences in the past, good relationship with partner, sexual knowledge and skills
90
# slides
Rubin's charmed circle
- circle of what is considered appropriate regarding sexual behaviors
- e.g. married vs in sin, heterosexual vs homosexual, free vs for money
