Wk 12: Sexual Dysfunction and Disorders

• Sexual dysfunction: a ‘heterogeneous group of disorders that are typically characterised by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure’
• Paraphilia: refers to an intense sexual fantasy, urge or behaviour involving an object, suffering or humiliation, or non-consenting partner, which causes distress to the person experiencing it.
• Paraphilic disorder: ‘a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm or risk of harm, to others

• Changes over time, across generations, culture, attitudes and beliefs.
• In some cultures, sexuality is viewed as an important part of wellbeing and pleasure, whereas in others, sexuality is seen as relevant only for procreation
• Cultures also vary in their acceptance of variations in sexual behaviour.

• The DSM-5 includes a diagnosis of gender dysphoria for people who experience a strong and persistent identification with the opposite sex. 
• Gender dysphoria is only diagnosed when the desire to be a member of the opposite sex causes marked distress or functional impairment.
• Many would argue that the distress reflects an internalisation of the stigma faced by people who violate gender roles.

• Cross-gender behaviour is universal. In countless species, biologically male animals will adopt behaviour, courtship rituals and mating strategies that parallel those seen in female animals.
•  In humans, most children engage in some form of play that violates gender roles.
• Surveys of hundreds of people one year after they have undergone such surgery indicate that more than 90 percent of people are satisfied and do not regret the surgery.

• But compared to women, men report thinking about sex, masturbating and desiring sex more often, as well as desiring more sexual partners, having more sexual partners, oral sex, anal sex, having more extramarital affairs, using condoms and engaging in cybersex.
• Women tend to report more fear, anxiety and guilt about sex and to be more ashamed of any flaws in their appearance than do men and this shame can interfere with sexual satisfaction.
•  For women, sexuality appears more closely tied to relationship status than for men. Men are more likely to think about their sexuality in terms of power than women.
• Men wanting more partners. These findings suggest that biology may shape men’s desire for many lifetime partners more than culture does.

• 1. Desire phase: This phase, introduced by Kaplan (1974), refers to sexual interest or desire, often associated with sexually arousing fantasies or thoughts.
• 2. Excitement phase: During this phase, men and women experience increased blood flow to the genitalia. In men, this flow of blood into tissues produces an erection of the penis. In women, blood flow creates enlargement of the breasts and changes in the vagina, such as increased lubrication.
• 3. Orgasm phase: In this phase, sexual pleasure peaks in ways that have fascinated poets and the rest of us ordinary people for thousands of years. In men, ejaculation feels inevitable and indeed almost always occurs (in rare instances, men have an orgasm without ejaculating and vice versa). In women, the outer walls of the vagina contract. In both sexes, there is general muscle tension.
• 4. Resolution phase. This last phase refers to the relaxation and sense of wellbeing that usually follow an orgasm. In men there is an associated refractory period during which further erection is not possible. The duration of the refractory period varies across men and even in the same man across occasions. Women are often able to respond again with sexual excitement almost immediately, a capability that permits multiple orgasms.

• Newer data calls into question the validity of distinguishing the desire and excitement phases for women.
• There is also some question about the way in which Kaplan defined the excitement phase by relying on biological changes. Subjective excitement may not mirror biological excitement for women.

• The DSM-5 divides sexual dysfunctions into three categories: those involving sexual desire, arousal and interest; orgasmic disorders; and a disorder involving sexual pain.
• Separate diagnoses are provided for men and women.
• The diagnostic criteria for all sexual dysfunctions specify that dysfunction should be persistent and recurrent and should cause clinically significant distress or problems with functioning. 
• A diagnosis of sexual dysfunction is not made if the problem is believed to be due entirely to a medical illness or to another psychological disorder.
• DSM-5 criteria for sexual dysfunction disorders specify that symptoms must last at least six months.
• 

 Oftentimes, people with problems in one phase of a sexual cycle will report problems in another phase.

• A. People with male hypoactive sexual desire disorder experience persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgement of deficiency is made by the clinician, taking into account factors that affect sexual functioning, such as age and general and sociocultural contexts of the individual’s life.
• The symptoms in Criterion A have persisted for a minimum duration of approximately six months.
• The symptoms in Criterion A cause clinically significant distress in the individual.
• The sexual dysfunction is not better explained by a non-sexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

An individual has erectile disorder if between 75–100 percent of sexual occasions (one of the three criteria must be present for six months):

• they have an inability to attain an erection
• they have an inability to maintain an erection for completion of sexual activity
• they have marked decrease in erectile rigidity

• People with female sexual interest/arousal disorder have a lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:
• absent/reduced interest in sexual activity
• absent/reduced sexual/erotic thoughts or fantasies
• no/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate
• absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75–100 percent) sexual encounters in identified situational contexts or, if generalised, in all contexts
• absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual)
• absent/reduced genital or non-genital sensations during sexual activity in almost all or all (approximately 75–100 percent) sexual encounters (in identified situational contexts or, if generalised, in all contexts).
• The symptoms in Criterion A have persisted for a minimum duration of approximately six months.
• The symptoms in Criterion A cause clinically significant distress in the individual.
• The sexual dysfunction is not better explained by a non-sexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

• Female sexual interest/arousal disorder,  Male hypoactive sexual desire disorder, erectile disorder.
• Postmenopausal women are two to four times as likely as women in their 20s are to report low sexual desire. On the other hand, older women are less likely to be distressed over low sexual desire.
• Women tend to be more concerned by a lack of subjective desire than by a lack of biological arousal.
• Most commonly, women with this disorder report that previously exciting stimuli, such as their partner’s touch or a sensual dance, no longer trigger desire.

• The prevalence of erectile disorder increases greatly with age.
• Data attest to the significance of subjective and cultural factors in defining low sex drive.

• Therefore, it is not surprising that about one-third of women report that they do not consistently experience orgasms with their partners.
•  Female orgasmic disorder is not diagnosed unless the absence of orgasms is persistent and troubling. 
• For many women, enjoying a sense of emotional closeness to their partner is more important than achieving an orgasm.

Females can be diagnosed with orgasmic disorder if between 75–100 percent of sexual occasions:

• they experience delay, infrequency or absence of orgasm, or
• they experience markedly reduced intensity of orgasmic sensation.

Premature ejaculation is diagnosed if in between 75–100 percent of sexual occasions there is a tendency to ejaculate during partnered sexual activity within one minute of penile insertion.

Delayed ejaculation is diagnosed if in between 75–100 percent of sexual occasions there is a marked delay, infrequency or absence of orgasm.

• The major symptom of genito-pelvic pain/penetration disorder is persistent or recurrent pain during intercourse.
• Women with this disorder often experience vaginismus, defined by involuntary muscle spasms of the outer third of the vagina to a degree that makes intercourse impossible.
• A first step in diagnosing genito-pelvic/penetration disorder is ensuring that the pain is not caused by a medical problem, such as an infection or by a lack of vaginal lubrication due to low desire or postmenopausal changes.
• Most women diagnosed with this disorder experience sexual arousal and can have orgasms from manual or oral stimulation that does not involve penetration.
• Women who experience pain when attempting sexual intercourse show normative sexual arousal to films of oral sex, but, not surprisingly, their arousal declines when they watch a depiction of intercourse which suggests that there is a psychological connection to consider.

People with genito-pelvic pain/penetration disorder experience 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 vaginal penetration

• Two immediate causes are fears about performance and the adoption of a spectator role.
• Spectator role refers to being an observer rather than a participant in a sexual experience.
• These immediate causes of sexual dysfunctions were hypothesised to have one or more historical antecedents, such as sociocultural influences, biological causes or sexual abuse.
• 

• Sexual dysfunctions are often embedded in a distressed relationship, so that many therapists work from a systems perspective in which a sexual problem is viewed as one expression of relationship problems.
• For women with sexual dysfunctions occurring in the context of relationship distress, behavioural couples therapy has been found to improve many aspects of sexual functioning.

• In their book Human Sexual Inadequacy, Masters and Johnson (1970)
• Couple 2 weeks in intensive therapy during day and completing sexual homework at night.
• But the basic emphasis was on relationship problems rather than the individual difficulties of either partner.
• The clients were introduced to the idea of the spectator role. worrying about performance, blocks natural responses and interferes with sexual enjoyment.
• Sensate-focus: 3rd day, do everything but sex.
• The one being touched was not required to feel a sexual response and was responsible for immediately telling the partner if something became uncomfortable. 
• The sensate-focus assignment usually promoted contact, constituting a first step towards re-establishing sexual intimacy.
• Realise that physical encounters could be intimate and pleasurable without necessarily being a prelude to sex.
• Next evening: give specific instructions on how to be pleasured.

• Many clients with sexual dysfunctions require gradual and systematic exposure to anxiety-provoking aspects of the sexual situation.
• Systematic desensitisation and in-vivo (real-life) desensitisation have been employed with some success.
• For example, a woman with genito-pelvic pain/penetration disorder might first receive psychoeducation about her body, be trained in relaxation and then practise inserting her fingers or dilators into her vagina, starting with inserting smaller dilators and working up to larger ones.

• Psychoeducation programs about sexuality also do plenty to reduce anxiety.
• Eg. videos demonstrating sexual techniques.
• Several studies have now shown that psychoeducation can be as effective as systematic desensitisation for male erectile disorder and for women with orgasmic disorder or low sexual arousal.

Anxiety about ejaculating too soon may be a natural result of an overemphasis on intercourse as a sole focus of sexual behaviour. Sex therapists advise couples to expand their repertoire of activities to include other ways of gratifying their partner both before and after the man has climaxed, such as oral or manual manipulation. When the exclusive focus on penile insertion is removed, anxieties about sex often diminish enough to enhance the man’s control over ejaculation.

• The sensate-focus exercises described in focus on discovery 9.2 are a way of helping the person focus on physical sensations as a counter to the destructive tendency to think about one’s performance or attractiveness during sex.
• A therapist might try to reduce the pressure a man with erectile dysfunction feels by challenging his belief that intercourse is the only true form of sexual activity.
• Women who are hypercritical of their appearance might be coached to consider more positive ways of viewing their bodies and their sexuality.

• Encouraging partners to communicate their likes and dislikes to each other has been shown to be helpful for a range of sexual dysfunctions.
• Communication training also exposes partners to potentially anxiety-provoking material, such as expressing sexual preferences, which allows for a desensitising effect.
• Skills and communication training is particularly warranted when sexual dysfunction is specific to a given relationship and was not a concern with previous partners.

• Directed masturbation was devised by LoPiccolo and Lobitz (1972) to enhance women’s comfort with and enjoyment of their sexuality.
• The first step is for the woman to carefully examine her nude body, including her genitals and to identify various areas with the aid of diagrams. Next, she is instructed to touch her genitals and to find areas that produce pleasure. Then she increases the intensity of masturbation using erotic fantasies. If orgasm is not achieved, she is to use a vibrator in her masturbation. Finally, her partner enters the picture, first watching her masturbate, then doing for her what she has been doing for herself and finally having intercourse in a position that allows him to stimulate the woman’s genitals manually or with a vibrator. As illustrated in the clinical case of Anne, directed masturbation has been shown to be helpful in treating orgasmic disorder.
• It is also helpful in the treatment of low sexual desire.

• For the treatment of female orgasmic disorder, couples may be taught specific sexual positions that increase the amount of clitoral stimulation.
• For the treatment of premature ejaculation, the squeeze technique is often used, in which a partner is trained to squeeze the penis in the area where the head and shaft meet to rapidly reduce arousal.
• This technique is practised without insertion and then during insertion, the penis is withdrawn and the squeeze is repeated as needed.
• In a similar approach, men are taught to withdraw their penis as needed during intercourse, so as to reduce arousal.

• Providing a blended approach of psychological and pharmacological intervention is currently the best recommended practice.
• For example, although premature ejaculation is often treated with medication alone, psychotherapy can help men regain confidence after experiences of these symptoms.

• Antidepressant drugs: particularly SSRIs. Antidepressant drugs have been found to be helpful when depression appears to contribute to diminished sex drive.
• Have also been found to be helpful in the treatment of premature ejaculation in a series of studies.
• A complicating factor, though, is that some antidepressants themselves interfere with sexual responsiveness! 
• Sometimes a second medication is used to counteract the sexual side effects of the first; for example, bupropion (Wellbutrin) has been shown to help address the libido problems caused by SSRIs.

• PDE-5 inhibitors: The most common intervention for erectile disorder such as viagra.
• Relax smooth muscles and thereby allow blood to flow into the penis, creating an erection during sexual stimulation but not in its absence.
• PDE-5 inhibitors are taken one hour before sex and the effects last about four hours. 
• Side effects: headaches and indigestion.
• PDE-5 inhibitors may be dangerous for men with cardiovascular disease and this is a concern since erectile dysfunction is often comorbid with cardiovascular disease.

• Paraphilic disorders: recurrent sexual attraction to unusual objects or sexual activities lasting at least six months.
• In other words, there is a deviation (para) in what the person is attracted to (philia).
• DSM differentiates the paraphilic disorders based on the source of arousal.
• As some of these behaviours become more common, considerable debate has emerged about whether it is appropriate to diagnose some of the paraphilias.
• The word disorder is added to the title of these diagnoses to emphasise that the 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 non-consenting person.
• Accurate prevalence statistics are not available for the paraphilic disorders. Research is limited by the lack of structured diagnostic interviews to reliably assess these conditions and even more by the reluctance of many people with paraphilias to reveal their proclivities.
• Most people with paraphilic disorders are male and heterosexual.
• The onset for many of the paraphilic disorders typically occurs during adolescence.
• Most people with a paraphilic disorder meet the criteria for other paraphilic disorders.

• A person has fetishistic disorder if, for at least six months, they have recurrent and intense sexually arousing fantasies, urges or behaviours involving the use of non-living objects or non-genital body parts.
• These symptoms cause significant distress or impairment in functioning.
• The sexually arousing object(s) are not limited to articles of clothing used in cross-dressing or to devices designed to provide tactile genital stimulation, such as a vibrator.

• A fetish refers to the object of these sexual urges, such as women’s shoes or feet.
• The person with fetishistic disorder, almost always a man, has recurrent and intense sexual urges towards these fetishes and the presence of the fetish is strongly preferred or even necessary for sexual arousal.
• The person with fetishistic disorder feels a compulsive attraction to the object; the attraction is experienced as involuntary and irresistible.
• The person with a boot fetish must see or touch a boot to become aroused and the arousal is overwhelmingly strong when a boot is present.

• A person has paedophilic disorder if, for at least six months, they experience recurrent and intense, sexually arousing fantasies, urges or behaviours involving sexual contact with a prepubescent child.
• The person will have acted on these urges, or the urges and fantasies cause marked distress or interpersonal problems.
• Paedophilic disorder is diagnosed if the person is at least 16 years old and at least 5 years older than the child.
• People with paedophilic disorder can be straight or gay, though most are heterosexual. Most older heterosexual men with paedophilic disorder are or have been married.
• Sexual arousal in response to pictures of young children can be measured by the penile plethysmograph.

• Outcomes after childhood sexual abuse: In one major community survey, about 20 percent of women and 5 percent of men reported experiencing some form of childhood sexual abuse.
• A child abuser is usually not a stranger.
• The abuser is often an adult whom the child knows and trusts.

• Effects on the child: About half of children who are exposed to CSA will develop symptoms, such as depression, low self-esteem, conduct disorder and anxiety disorders like post-traumatic stress disorder (PTSD).
• On the other hand, almost half of children who are exposed to CSA do not appear to experience immediate symptoms.
• The odds that CSA will produce clinically significant symptoms are increased when a perpetrator threatens the child, the child blames himself or herself or the family is unsupportive.
• Negative outcomes are more pronounced when the CSA involves sexual intercourse.
• Symptoms also appear to be more likely when the CSA started at an earlier age.
• A history of CSA is common among adults experiencing many different psychological disorders- dissociative identity disorder, PTSD, eating disorders, borderline personality disorder, major depressive ­disorder, sexual dysfunctions and substance abuse.
• CSA is also related to changes in the function of the HPA axis and the regulation of the stress hormone, cortisol, during adulthood.
• An issue in interpreting these correlations is that families in which abuse occurs are often experiencing a broad array of problems, such as substance dependence in one or both parents, which may be entangled with other genetic and environmental risks for psychopathology. 
•  In one study of almost 2000 twin pairs, adults with a history of CSA had substantially increased risk of depression, suicide, conduct disorder, alcohol dependence, social anxiety, rape and divorce compared to their non-abused twins.

• Dealing with the problem: When they suspect that something is awry, parents must raise the issue with their children.
• The child’s own report is the primary source of information about whether CSA has occurred. 
• The problem is that leading questions can produce some false reports.
• Many interventions are similar to those used for PTSD in adults; the emphasis is on exposure to memories of the trauma through discussion in a safe and supportive therapeutic atmosphere.

• A subtype of paedophilic disorder.
• Incest: sexual relations between close relatives for whom marriage is forbidden.
• It is most common between brother and sister, next most common between father and daughter.
• The taboo against incest is virtually universal in human societies.
• The offspring from a father–daughter or a brother–sister union have a greater probability of inheriting a pair of recessive genes, one from each parent. 
• The incest taboo, then, has adaptive evolutionary significance.

• People have voyeuristic disorder if, for at least six months, they experience recurrent and intense sexually arousing fantasies, urges or behaviours involving the observation of unsuspecting others who are naked, disrobing or engaged in sexual activity.
• Voyeuristic disorder is diagnosed if the person has acted on these urges with a non-consenting person or the urges and fantasies cause marked distress or interpersonal problems.

• People with voyeuristic disorder achieve orgasm by masturbation, either while watching or later while remembering the peeping.
• The element of risk seems important, for the voyeur is excited by the anticipation of how the woman would react if she knew he was watching.
• Seldom attempt to contact stranger.

• A person with exhibitionistic disorder will experience, for at least six months, recurrent, intense and sexually arousing fantasies, urges or behaviours involving showing one’s genitals to an unsuspecting person.
• Exhibitionistic disorder is diagnosed if the person has acted on these urges to a non-consenting person or the urges and fantasies cause clinically significant distress or interpersonal problems.

• Seldom attempt to contact stranger.
• Many exhibitionists masturbate during the exposure.
• In most cases, there is a desire to shock or embarrass the observer. 
• In the tension of the moment, many describe symptoms of anxiety, including headaches, palpitations and derealisation. Because of the compulsive nature of the urge, the exposures may be repeated often and typically in the same place and at the same time of day.
• After exposing themselves, exhibitionists tend to flee and feel remorseful.

• Frotteuristic disorder is diagnosed if the person, for at least six months, experiences recurrent and intense and sexually arousing fantasies, urges or behaviours involving touching or rubbing against a non-consenting person.
• Frotteuristic disorder is diagnosed if the person has acted on these urges with a non-consenting person or the urges and fantasies cause clinically significant distress or problems.

These attacks typically occur in places such as a crowded bus or sidewalk that provide an easy means of escape.

• Sexual sadism disorder is diagnosed if, for at least six months, the person experiences recurrent, intense and sexually arousing fantasies, urges or behaviours involving the physical or psychological suffering of another person.
• Sexual sadism disorder is diagnosed if the symptoms cause clinically significant distress or impairment in functioning or the person has acted on these urges with a non-consenting person.

• There is also some concern that the diagnosis of sexual sadism disorder is rarely applied in clinical settings.
• The diagnosis, then, seems to be applied almost entirely within forensic settings.

• Sexual masochism disorder is diagnosed if, for at least six months, the person has experienced 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.

• Findings hard to interpret because sample is mostly male charged with sexual offences. Also differences in severity of offenders and age.
• Also unethical to put people in no treatment group so most studies are retrospective comparing people who got treatment and no treatment.
• Most studies did not do follow up.

Strategies to enhance motivation: a therapist can bolster the client’s hope that he can gain control over his urges through treatment, highlight the potential legal and other consequences of continued engagement in the same sexual behaviour and note that plethysmograph assessments will make it hard to ‘fake’ a recovery.

• CBT: aversion therapy, covert sensitisation (imagine arousing thing and then also imagining feeling shame etc).
• Cognitive procedures are often used to counter the distorted thinking of people with paraphilic disorders.
• Current approaches supplement these traditional approaches with techniques such as social skills training and sexual impulse control training.
• Training in empathy towards others.
•  A therapist who uses relapse prevention techniques would help a person identify situations and emotions that might trigger symptomatic behaviour.

• Biological treatments:  Hence, hormonal agents that reduce androgens have been used to treat paraphilic disorders.
• Randomised controlled trials show that these agents reduce arousal to deviant objects, as measured using the penile plethysmograph.
• Informed consent concerning these risks must be obtained and many patients will not agree to use these drugs long-term.
• Beyond drugs that influence hormones, SSRI antidepressants are commonly used

• Beyond the lack of research and the small sample sizes, most of the research focuses on men who are arrested for their sexual behaviour; very little is known about those whose sexual behaviour does not lead to arrest.
• Hence, much of this literature is most relevant for understanding sexual offenders, who represent a more severe subset of those with paraphilic disorders.

• Neuropbiological factors: Because the overwhelming majority of people with paraphilic disorders are men, there has been speculation that androgens (hormones such as testosterone) play a role.
• Androgens regulate sexual desire and sexual desire appears to be atypically high among sexual offenders with paraphilic disorders.
•  Having said that, men with paraphilic disorders do not appear to have high levels of testosterone or other androgens.

• Childhood sexual abuse: about two-thirds of sexual offenders reported a history of sexual abuse, a rate that is more than threefold higher than the rate among those charged with non-sexual offences.
• However other follow up studies of boys with confirmed sexual abuse, fewer than 5% were charged with any type of sexual offence as adults.

• Psychological factors: Psychological research tends to consider the immediate triggers of sexual behaviour and the more distal personality and cognitive risk factors for paraphilic disorders.
• For some of the paraphilias, succumbing to the sexual urge can be thought of as an impulsive act, in which the person loses control over their behaviour. Alcohol decreases the ability to inhibit impulses and, accordingly, incidents of paedophilic disorder, voyeuristic disorder and exhibitionistic disorder often occur in the context of alcohol use.
• Others report that their sexual behaviours are most likely to happen in the context of negative moods, suggesting that sexual activity is being used as a means to escape from negative affect.
• People with paraphilic disorders do tend to show heightened impulsivity and poor emotional regulation.
• Men who engage in paraphilias that involve non-consenting women may have hostile attitudes and a lack of empathy towards women. 
• Others may have distortions in the ways they think about their sexual behaviour. For example, a voyeur may believe that a woman who left her blinds up while undressing wanted someone to look at her.
• Men who engage in rape may blame the woman, saying that she ‘deserved a lesson’ or that her dress was provocative.
• Psychological traits: On average, men with paedophilic disorder have a slightly lower IQ and higher rates of neurocognitive problems than the general population.
• Academic problems are common, as are other criminal behaviours.

• In Australia, a post-sentence preventive detention order is available, which allows a person post-sentence to be detained indefinitely in prison to ensure adequate protection of the community if a person is deemed to have committed a serious sexual offence.
• In addition to the post-sentence supervision, all Australian jurisdictions have a process for registering sex offenders to monitor their location upon release from prison.
• Once on the register, offenders are prohibited from working in child-related employment.