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Considerations for 'normal' sexual behaviour?
- Must consider in light of:
- Time and place
- Gender
- -Attitudes towards casual and premarital sex
- -Patterns of arousal
- -Sexual self-concept
- -Reporting dysfunction
- Culture: belief systems
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Difficulties in defining what is 'normal'
- Over reliance in research on:
- Self-report, clinical impressions
- Extensive use of clinical groups without using non-clinical controls
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Masters and Johnson's 1966 & Kaplan (1974)
- Desire phase
- Excitement phase
- Orgasmic phase
- Resolution phase
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Sexual dysfunction must be:
- Persistent and recurrent: at least 75% of sexual experiences
- Cause clinically significant distress
- Not due to a medical condition/other psychological illness: vascular, hormonal, physical
- Present: during masturbation, during partnered sexual activity.
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Specifiers used to designate onset
- Lifelong- present from first sexual experience
- Acquired: develop after period of relatively normal sexual function
- Generalised: no limited to certain types of stimulation, situation, partner
- Situational: only with certian types of stimulation, situation, partner
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Factors considered during assessment
- 1. Partner factors: partner's sexual problems, health status
- 2. Relationship factors: poor communication, discrepancies in desire
- 3. Individual vulnerability factors: body image, history of abuse, psychiatric comorbidity, stressors
- 4. Cultural/religious factors: prohibitions, attitudes towards sexuality
- 5. Medical factors: eg. pelvic nerve damage
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Common diagnostic criteria and symptoms not better explained by
- 1. Symptoms must have persisted for a minimum duration of 6 months
- 2. Symptoms must cause clinically significant distress
- Symptoms not better explained by:
- 1. non-sexual mental disorder
- 2. severe relationship distress, partner violence
- 3. other significant stressor
- 4. Effects of substance/medication
- 5. Other medical condition.
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other specific sexual dysfunction and unspecified sexual dysfunction
- Significant distress but symptoms do not met full criteria
- Significant distress but specific reason doesn't meet criteria eg. sexual aversion
- Unspecified sexual dysfunction: as above but typically insufficient information to make specific diagnosis.
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Aetiology of sexual dysfunction: biological contributions
- Organic problems: neurological (eg. MS), diabetes. Anxiety associated with cardiovascular disorder
- Prescription medication: antihypertensives, anxiolytics, antidepressants, tranquilisers
- Illicit drugs: marijuana, opiates (heroin), cocaine
- Alcohol:reduces inhibitions- more willing to have sex, not more aroused.
- Smoking
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Psychological contributions-functional
- 1. Explicit/implicit demand for sexual performance
- 2. Positive affect and expectancies, accurate reporting of arousal, perception of control
- 3. Attentional focus on erotic cues
- 4. Increased autonomic arousal
- 5. Increasingly efficient
- 6. Functional performance
- 7. Approach
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Psychological contributions- dysfunctional
- 1. Explicit/implicit demand for sexual performance
- 2. Negative affect and expectancies, accurate reporting of arousal, perception of control
- 3. Attentional focus on public consequences of not performing or other non-erotic issues
- 4. Increased autonomic arousal
- 5. Increasingly efficient attentional focus on consequences of not performing etc
- 6. Dysfunctional performance
- 7. Avoidance
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Aetiology of sexual dysfunction: social and cultural contributions
- Cultural and religious influences most common cause
- Significant negative traumatic event: rape, incest, traumatic experiences in initial sexual exposure
- Marked deterioration in close interpersonal relationships
- Sexual inexperience: restrictive range of behaviours
- Interaction of psychological and physical factors: socially transmitted negative attitudes interact with relationship issues and predispositions to develop performance anxiety
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Treatment of sexual dysfunction
- Providing basic education about sexual functioning
- -altering deep seated myths
- -Cognitive/behavioural approach to therapy
- -Schema therapy
- Dynamic therapy: increasing communication between partners
- Eliminating psychologically based performance anxiety:
- Medications and physical treatments:
- Antidepressants: where depression contributes to reduced sex drive?
- -Early ejaculation
- Phosphodiesterase type 5 inhibitor (eg. viagra) for erectile disorder
- -relax smooth muscles (allow blood to penis)
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The paraphilias
- Defined by intense, persistent and recurrent sexual attraction to unusual objects or sexual activities
- Lasting at least 6 months
- Diagnosed only when they cause marked distress or impairment (social, occupational or other important area of functioning) or engages non-consenting others
- Disproportionately men, rare in women
- Prevalence is underestimated: less likely to report if it is illegal. Not distressing for some people.
- May cause untold suffering for self and sometimes others- common to exhibit comorbid mood, anxiety and substance abuse disorders
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Fetishistic disorder
- Fantasies, urges, or behaviours involving the use of nonliving objects or nongenital body parts.
- -causes significant distress or impairment in functioning
- Experienced as involuntary/irresistible, can be necessary for arousal
- Usually begind adolescence- significance earlier?
- Often coexists with pedophilia, sadism, masochism disorder
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Transvestic disorder
- Fantasies, urges or behaviours involving cross-dressing
- WIth fetishism: if sexually aroused by fabrics, materials or garments
- With autogynephilia: if sexually around by thoughts or images of self as female
- Compensation not unusual eg. associating with 'macho' activities
- Often coexists with macochism
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Voyeuristic disorder
- Fantasies, urges or behaviours involving the observation of unsuspecting others who are naked, disrobing, or engaging in sexual activity.
- Person has acted on these urges with a nonconsenting person or the urges or fantasies cause marked distress or interpersonal problems.
- Almost always male- begins adolescence
- Sometimes essential for arousal
- Element of risk important- not exciting if consensual
- Prevalence unknown
- Other paraphilias common, tend not to have other mental disorders.
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Exhibitionistic disorder
- Fantasies, urges, or behaviours involving showing one's genitals to an unsuspecting stranger.
- Person has acted on these urges with a nonconsenting person, or the urges and fantisies cause clinically significant distress or interpersonal problems.
- Seldom attempts to actually contact with the stranger
- Triggered by anxiety and restlessness as well as sexual arousal
- Most cases desire to shock or embarass
- Often remorseful: most common self-referral
- Other paraphilias common, especially voyeuristicism & frotteruristic disorders
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Frotteuristic disorder
- Fantasies, urges or behaviours involving touching or rubbing against an unconsenting person.
- Person has acted on these urges with a non consenting person, or the urges and fantasies cause clinically significant distress or problems.
- Often begins in adolescence- sexual inexperience
- usually crowded places- easy escape or 'accidental cause'
- More common in males: up to 30% of males display this behaviour (sub clinically)
- Occurs along with other paraphilias
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Sexual sadism/masochism disorders
- Sexual sadism disorder: fantasies, urges or behaviours involving physical or psychological suffering of another person.
- Causes clinically significant distress or impairment in functioning or the person has acted on these urges with a non consenting person.
- Sexual masochism disorder
- Fantasies, urges or behaviours involving the act of being humiliated, beaten, bound or made to suffer.
- Causes marked distress or impairment in functioning.
- Specify with or without asphixiophilia.
- Relatively acceptable- debate about inclusion in DSM.
- Both begin in early childhood 20-30% female
- Most lead otherwise conventional lives.
- Most sadomasochistic behaviours mild & harmless- can become dangerous.
- Extreme example is sadistic rape.
- No single profile-motivation & aetiology of behaviour difficult to determine
- -hostility towards women
- -high incidence of sexual dysfunction, inc during rape
- -Profile similar addiction (tolerance)
- -Biological link= similar physiological arousal
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Paedophilic disorder
- Fantasies, urges, or behaviours involving sexual activity with a prepubescent child.
- Arousal is as strong or stronger for children than for adults.
- Person has acted on these sexual urges, or the urges or fantasies cause clinically significant distress or interpersonal problems.
- Prevalence: under diagnosed
- 90% of abusers are male
- Involve children they know- changing with internet
- Any male can become aroused by erotic pictures of children.
- Most not violent outside of sexual act- this can be seen in some grooming patterns
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Paedophilia: cognitive distortions
- Misattributing blame: she started by being too cuddly
- Denying sexual intent: I was just teaching her about sex... better from her father than from someone else
- Debasing the victim: She'd had sex before with her boyfriend
- Minimising consequences: She has always been friendly to me, even afterwards
- Deflecting censure: This happened years ago. Why can't everyone forget about it?
- Victim empathy deficits: He wasn't crying or anything, so whats the problem
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Paedophilic disorder: effects on the victim
- 1/2 of children exposed to childhood sexual abuse develop symptoms: depression, low self-esteem, anxiety disorders (eg. PTSD)
- History of CSA common among adults with mental disorders: dissociative identity disorder, major depressive disorder, eating disorder, borderline personality disorder, sexual dysfunction, substance abuse
- Increased likelihood of developing a disorder if:perpetrators threatens child, child blames him/herself, unsupportive family, earlier age, involves intercourse
- But families in which abuse occurs often experiencing other problems: substance dependance of parents, other genetic and environmental risks for psychopathology.
- Therefore hard to isolate whether CSA= heightened risk for a clinical disorder.
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Aetiology of paraphilias
- Biological factors:
- -genetic predisposition
- -Excess levels of male hormones
- -Neurological differences- temporal lobes changes
- Developmental and psychological factors:
- - disordered relationships during childhood/adolescence
- -Physical or sexual abuse
- -Operant/classical conditioning
- -OCD- similar paradoxical increase in frequency & intensity
- -Cognitive distortions/unwarranted beliefs
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Treatments of paraphilias
- Focus on engaging client.. often difficult to do:
- -Shame/stigma associated with help seeking
- -Lack motivation to do so
- Risk assessment: identifying high risk situations for re-emergence of symptoms or offending.
- Cognitive behavioural therapy:
- -aversion therapy- associate negative feelings with inappropriate object
- -Challenge distorted beliefs about consequences
- -Improve social skills, impulse control, increase empathy
- Rescripting fantasy: engages in fantasy- at moment of climax switch to normal/healthy fantasy
- -little empirical support
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Treatments of paraphilias: biological treatments
- Castration prior to hormonal treatments
- Medications:
- -particularly among high risk sex offenders
- -Hormonal agents to reduce androgens (reduces libidos)
- Chemical castration
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Gender dysphoria
- Marked incongruence between one's experienced/expressed gender and assigned gender
- Differs from hermaphrodism- no physical abnormalities, maybe some biological explanation for behaviour.
- Independent of sexual arousal patterns/sexual orientation.
- Rare in Australia
- In adolescence/adults- desire to be rid of sex characteristics. Desire to be treated as other gender
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Aetiology of gender dysphoria
- Genetic/neurobiological factors?
- -support from twin studies
- Psychosocial factors
- -reinforcement of X gender behaviour received little support
- Controversial status as a disorder (natural diversity?)
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Treatment of gender dysphoria
- Most common to change body to suit gender identity
- Hormones to change features
- Sex reassignment surgery
- Surgery- evidence of high satisfaction
- Behavioural treatment= succesful in changing incongruous behaviours but not representative of most GDs who want to physically change their bodies
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Case Bruce (twin)
- Accidentally castrated
- Brought up as girl
- Felt like he wasn't a girl
- Was given Oestrogen hormones
- When found out about incidence, took testosterone and lived as male.
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Another case similar
- But was fine
- Attracted to both sexes
- Showed effects of environment
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