Exam 3 (Drugs, Sex, and Eating Disorders)

Two categories of sexual disorder

Sexual dysfunctions and Paraphilic disorders

Sexual dysfunctions

Problems with sexual responses

Criteria for diagnoses: must cause significant distress to the individual for diagnosis

Paraphilic disorders

Repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations

4 phases of sexual response

Desire, excitement, orgasm, and resolution

Desire

Sparked by anything that prompts sexual interest

Excitement

Noticing physical changes in one’s body

Orgasm

Involves muscle contraction

Resolution

Positive feelings after orgasm

Sexual dysfunctions

affect one or more of the first three phases, 30% of men and 43% of women in the U.S.

Impact of Sexual Dysfunction

Typically very distressing, and often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems

dysfunctions are interrelated; many patients with one dysfunction experience another as well

The Normal Sexual Response Cycle

female and male cycles

Disorders of Desire

Male hypoactive sexual desire disorder and Female sexual interest/arousal disorder

Male hypoactive sexual desire disorder

Characterized by a lack of interest in sex and little sexual activity

Not repulsed by sexual activity at all, and physical responses tend to be normal

Prevalent in about 16% of men

Female sexual interest/arousal disorder

Characterized by a lack of normal interest in sexual activity and physical responses tend to be abnormal

Rarely initiate sexual activity and may experience little excitement during sexual activity

Low sexual desire: Biological Causes

Hormones, Neurotransmitters, medications

Hormones related to a low sex drive

Low testosterone levels

low or high estrogen levels

High prolactin levels (prolactin -> best known for helping produce breast milk)

Neurotransmitters

Excessive activity of the NTs serotonin and dopamine lowers sexual desire

Medication that may lower sex drive

Birth control pills, Pain medication, Psychotropic drugs, Illegal drugs

Low sexual desire: Psychosocial Causes

increase in anxiety, depression, or anger

Fears, attitudes, and memories may contribute to sexual dysfunction

Certain psychological disorders, including depression and OCD

Low sexual desire: Social Causes

Situational Pressures, such as divorce or work stress

Trauma: Sexual molestation or assault is especially likely to produce aversion to sexual activity or hypoactive sexual desire

Excitement Phase of Desire

Marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing

In men: erection of the penis

In women: swelling of the clitoris and labia and vaginal lubrication

erectile disorder: excitement

involves dysfunction in the excitement phase only

Disorders of Excitement: Erectile Disorder

Characterized by persistent inability to attain or maintain an erection during sexual activity, affects 50% of men, result from an interaction of biological, psychological, and sociocultural processes

Erectile Disorder: Biological Causes

Hormonal imbalances

Most commonly, vascular problems are involved

Damage to the nervous system from various diseases, disorders, or injuries

Medications and substance abuse may interfere with erections

Diagnosing biological causes of ED

measuring nocturnal penile tumescence (NPT)

“snap gauge” band

measuring nocturnal penile tumescence (NPT)

Men typically have erections during REM sleep - abnormal or absent nighttime erections usually indicate a physical basis for erectile failure

“snap gauge” band

If the man wakes up in the morning and it is unbroken, his ED likely has a physical basis

Erectile Disorder: Psychosocial Causes

Performance Anxiety and the spectator role,

Up to 90% of men with severe depression experience some degree of ED

Job and marital distress are particularly relevant

Performance Anxiety and the spectator role

Once a man begins to have erectile difficulties, he becomes fearful and worries during sex; instead of being a participant, he becomes a spectator and judge

Orgasm phase of the sexual response cycle

Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically

For men: semen is ejaculated

For women: the outer third of the vaginal walls contract

Three disorders of phase of Orgasm

Premature ejaculation

Delayed ejaculation

Female orgasmic disorder

Disorders of Orgasm: Ejaculation Disorders

Premature ejaculation and Delayed ejaculation

Premature ejaculation

Ejaculation within one minute of beginning of sex and before he wishes

As many as 30% of men experience rapid ejaculation at some time

Unlike ED, common in men throughout the lifespan

Delayed ejaculation

Repeated inability to ejaculate or very delayed ejaculation during sex 75% of the time, without the individual desiring delay

Biological causes of delayed ejaculation

low testosterone, neurological disease, and head CNS injury

Medications, that slows down sympathetic NS (i.e. antidepressants) may have an effect

Psychological causes of delayed ejaculation

Appears to be performance anxiety and cognitive factors involved in ED

Another psychological factor may be past masturbation habits

Disorders of Orgasm: Female Orgasmic Disorder

Characterized by persistent failure to reach orgasm, experiencing orgasms of very low intensity, or delay in orgasm

Women who reach orgasm during masturbation but not during sex do not have this disorder

Disorders of Orgasm: Female Orgasmic Disorder Statistics

24% of women appear to have problems experiencing orgasm at least

to some degree.

10% or more have never reached orgasm

An additional 9% reach orgasm only rarely

More common in single women than in married or cohabiting women

Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly

Female Orgasmic Disorder (FOD) sociocultural theory

Female orgasmic problems occur due to society’s sexual double standards against women

Research does not support these ideas

Biological causes Female Orgasmic Disorder (FOD)

diabetes and multiple sclerosis

The same meds/drugs, and hormones that affect ED may be responsible in FOD

FOD: Psychological Causes

Same as causes interfering with arousal, including depression

Memories of childhood trauma (such as sexual assault) and relationship

• A mother and father who were affectionate with each other

• Mother’s positive personality

• Mother’s open expression of positive emotions

• Dependable father

• Overall, a happy childhood

aspects of women who have healthy orgasm report

Genito-pelvic pain/penetration disorder (GPPD)

Enormous physical discomfort (not necessarily pain) during intercourse

Experienced by women much more often than men

Vaginismus

involuntary contractions of the muscles of the outer third of the vagina

Severe cases can prevent a woman from having intercourse

This problem has received relatively little research, but estimates are that it occurs in fewer than 1% of all women

Dyspareunia

Severe pain during intercourse (no muscle contractions)

As many as 14% have this

GPPD: Causes

Vaginismus: Most clinicians agree that this is a learned fear response from classical conditioning

Dyspareunia: Usually has a physical cause, most commonly from injury sustained in childbirth; but also possibly from infection or disease

Dyspareunia

Usually has a physical cause, most commonly from injury sustained in childbirth; but also possibly from infection or disease

Modern sex therapy is short-term and instructive

Therapy typically lasts 15 to 20 sessions

It is centered on specific sexual problems rather than on broad personality issues

Sex Therapy: Features

Assessment and conceptualization of the problem

 Mutual responsibility

 Education about sexuality

 Emotion identification

 Attitude change

 Elimination of performance anxiety and the spectator role

 Increasing sexual and general communication skills

 Changing destructive lifestyles and marital interactions

 Addressing physical and medical factors

Sex Therapy for Disorders of Desire

Affectual awareness

Self-instruction training

Behavioral techniques

Hormone treatment

Affectual awareness

Patients visualize sexual scene and monitor negative emotions (i.e. anxiety)

Self-instruction training

Replacing negative statements associated sex with positive ones

Behavioral techniques

Keep a desire diary, read books and watch films with erotic content, pleasurable activities with spouse which involve physical context (not necessarily sexual)

Sex Therapy: Erectile Disorder

Treatments for ED focus on reducing a man’s performance anxiety and/or increasing his stimulation

CBT may be helpful, exposure and self-instruction training

Viagra or other drugs

Couples told to refrain from having intercourse and focus on bodily

pleasure instead

May include sensate-focus exercises such as the “tease technique”

Partner caresses man until erection, and stops after man achieves erection. Then repeat.

Teaches participant that erections occur naturally to stimulation and not to focus so much on performance.

Sex Therapy: Premature ejaculation

Premature ejaculation has been successfully treated for years by behavioral procedures such as the “stop-start” or “pause” procedure

Some clinicians use SSRIs, the serotonin-enhancing antidepressant drugs

Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation

Many studies have reported positive results with this approach

Sex Therapy: Delayed ejaculation

Therapies for this disorder include techniques to reduce performance anxiety and increase stimulation

When the cause of the disorder is physical, treatment may include a drug to increase arousal of the sympathetic nervous system

Sex Therapy: Female Orgasmic Disorder

cognitive-behavioral techniques, self-exploration, enhancement of body awareness, and directed masturbation training

80-90% learn to have orgasms through masturbation when self-directed and partner-induced.

• 30% learn to have orgasms through intercourse

• Biological treatments, including hormone therapy not helpful

Sex Therapy: GPPD

Specific treatment for involuntary contractions of the vaginal muscles

Different approaches are used to treat severe vaginal or pelvic pain during intercourse

Specific treatment for involuntary contractions of the vaginal muscles

Practice tightening and releasing the muscles of the vagina to gain more voluntary control

Overcome fear of penetration through gradual behavioral exposure treatment

Results: Most women treated using these methods eventually report pain-free intercourse

approaches are used to treat severe vaginal or pelvic pain

Given that most cases are caused by physical problems, pain management techniques and medical intervention may be necessary

Paraphilic Disorders

Intense sexual urges, fantasies or behaviors that are outside social norms, including:

 Nonhumans

 Children

 Nonconsenting adults

 The experience of suffering or humiliation

 Humans who are no longer alive

Paraphilic Disorders: Diagnostic Issues

Urges must be present for at least 6 months

Only when the urges, fantasies, or behaviors cause significant distress or impairment OR when the disorder places the person or others at risk of harm– either currently or in the past

Paraphilic Disorders: Causes/Explanations

Many attempts have been made

None have strong research support

Paraphilic Disorders: Biological Treatment

antiandrogens that lower the production of testosterone

Clinicians are also increasingly administering SSRIs to (hopefully) reduce the compulsion-like sexual behaviors

Both drugs also have a common side effect of lowered sexual arousal

Paraphilic Disorders: Behavioral Treatments

Aversion Therapy, Covert sensitization, Masturbatory satiation, Orgasmic Reorientation

Aversion Therapy

Pairing the desired object with an unpleasant stimulus repeatedly

Client would likely need to continue this outside of therapy

Covert sensitization

Having the client imagine the desired object along with an imagined unpleasant stimulus

Masturbatory satiation

Client masturbates to appropriate object until orgasm, then masturbates for a long period of time (boredom) while imagining the fetish object

Orgasmic Reorientation

Clients are taught to re-direct their sexual desire toward more appropriate sources of sexual stimulation through classical conditioning

Fetishistic Disorder

Recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object, or nonsexual bodypart often to the exclusion of all other stimuli

Causes of fetish disorder

Unknown, although experiments have found they were able to create fetishes in people using classical conditioning

However, this does not necessarily indicate that that is how it typically starts for those with fetishes.

Transvestic Disorder

Also known as transvestism or cross-dressing

Characterized by fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal

The typical person with this disorder is a heterosexual male who began cross-dressing in childhood or adolescence

Exhibitionistic Disorder

Characterized by arousal from the exposure of genitals in a public setting

Most often, the person wants to provoke shock or surprise, rather than initiate sexual contact

Sexual contact rarely initiated or desired

Any kind of reaction is a good reaction for them

Exhibitionistic Disorder treatment

includes aversion therapy and masturbatory satiation

May be combined with orgasmic reorientation, social skills training, or cognitive-behavioral therapy

Voyeuristic Disorder

Characterized by repeated and intense sexual urges to observe people as they undress or engage in sexual activity, without their consent

The person may masturbate during the act of observing or while remembering it later

The risk of being discovered often adds to the excitement

Frotteuristic Disorder

recurrent and intense fantasies, urges, or behaviors involving touching and rubbing against a non-consenting person

Almost always male, the person often fantasizes during the act that he is having a caring relationship with the victim

Symptoms generally decrease and disappear with no intervention after age 25

Pedophilic Disorder

Fantasies, urges, or behaviors involving sexual arousal from prepubescent or early pubescent children

Overall, 2/3 of victims of pedophilia are girls

Prevalence – Highest possible rate is 3-5% of males; less than 3% of females

Pedophilic disorder emerges during adolescence.

Some people with this disorder were sexually abused as children.

Many are immature, display distorted thinking, and have an additional psychological disorder; often sexual difficulties when married.

Most people are imprisoned or forced into treatment if caught

Pedophilic Disorder: Characteristics

Virtuous Pedophiles: Opposed to any inappropriate contact with children for themselves and other pedophiles, despite urges

Virtuous Pedophiles typically experience great psychological distress and plead for help with their anxiety and depression (guilt), and are often scared to seek help

Virtuous Pedophiles: Causes/Explanations

Childhood:

Some were sexually abused as children

Many were neglected, excessively punished, or deprived of close relationships in childhood

Cognitive and Psychological:

Most are immature, display distorted thinking, and have an additional disorder

No known biological factors

Treatment for Pedophiles

Antiandrogens and CBT for relapse prevention training (modeled after the relapse prevention training for substance use

Sexual Masochism Disorder

This disorder is characterized by fantasies, urges, or behaviors involving the act or thought of being humiliated, beaten, bound, or otherwise made to suffer

Hypoxyphiilia

Strangling themselves or smothering themselves, or asking a partner to – to enhance their sexual pleasure

Autoerotic asphyxia

Strangling or suffocating themselves, while suffocating, and accidentally inducing a fatal lack of oxygen (RIP)

Sexual Sadism Disorder

Repeated and intense arousal by the physical or psychological suffering of another individual

This arousal may be expressed through fantasies, urges, or behaviors

People who fantasize about sadism imagine they have total control over a sexual victim

Sexual Sadism Disorder causes and treatment

Causes unknown

Biological studies have found signs of possible brain and hormonal abnormalities, but more research is needed

The primary treatment for this disorder is aversion therapy

Sex

Refers to DNA (XX chromosomes = Female; XY chromosomes = male)

But there are exceptions: termed intersex

Sexuality

Attraction to same or opposite sex (or both), generally operates along a spectrum

Men (especially heterosexual men) tend to be more rigid in sexuality than women

Gender Identity – Sense of being male or female

Initially, thought of as a sense of masculine and/or feminine traits

Can vary along a spectrum, including nonbinary (identify as neither gender)and gender fluid (identify as both genders, but varies over time)

Gender can conform with biological sex, making someone cisgender

Transgender

Individuals whose gender identify is at odds with their biological sex

Biological factors: trans

Transgender functions may be familial

Social factors

Some suggest rapid increase in transgender population may be due to social contagion

Increased access to information online, greater acceptance in society

However, this view is highly controversial

Environmental factors

Findings suggest that exposure to endocrine disruptors (hormone disruptors such as plastics and pesticides) can influence gender identity in the womb

Transgender care

Puberty blockers, Hormone therapy, Gender affirming surgery

Puberty blockers

But these are dangerous for growth and natural development

Generally not recommended, especially because of reasons we will discuss shortly

Hormone therapy for Transgender

Physicians may prescribe estrogen and antiandrogens for transgender women (reduce production of testosterone)

Vice versa, transgender men may take testosterone

Will lead to physical alterations in body (e.g., development of breasts, changes to facial hair, changes to muscle mass, etc.)

Gender affirming surgery

Reconstructive surgery (including genital reconstruction)

Not always recommended, because surgery is irreversible (especially if they suffer from gender dysphoria

Gender Switching

Many experts generally recommend against gender affirming procedures (especially irreversible ones) before the age of 16

Ultimately, consent and understanding of the individual is most important before undergoing such procedures

Gender Dysphoria

A pattern in which people feel that they have been born to the wrong sex

People with this disorder would like to get rid of their sex characteristics and acquire the characteristics of the other sex

This causes great distress

Gender Dysphoria and Transgender

Some individuals with “gender dysphoria” are transgender, whereas others may choose to identify as cisgender as they age

E.g., children may have feelings of want to change gender, but these subside by adolescence

Difficult to distinguish between two mindsets