Sex, sexuality, gender, sexual dysfunctions, paraphilias

Why is sex important?

Positive and enjoyable sexual expression contributes significantly to overall well-being (both psychologically and physiologically), not simply absence of disease

Human beings seek social and sexual bonds for security, nurturance, as well as for pleasure and procreation

Struggling to achieve a balance between social warmth, sense of belonging, and rewarding sex in intimate relationships can lead to powerful feelings of despair

I.e., Sex can have important implications for well-being that ranges from deeply distressing to fulfilling needs for human connection

What are physiological effects of sex?

• Longevity

• Immunity

• Youthfulness

• Sleeping

• Heart disease, stroke

• Risk of some cancers

• General health

• Pain

• Mortality

Why is it important for a psychologist to be sex positive?

Sex is an important part of being human

Positive sexual expression = contributes to overall well-being

Be aware of your own values and attitudes about sex when working with clients

Judgement = shame

Normalising variations in sexual preference from deviant preferences

What are key points about gender dysphoria?

• Not a disorder, pathology or something 'wrong' in the person - it is distress from poor fit between assigned gender and identity. • Can wax and wane but won't spontaneously disappear. • The cost of not treating, if treatment is desired, is very high. Contrast: 'gender euphoria'. • DSM-5: Gender Dysphoria (previously Gender Identity Disorders) has its own section, separate from sexual dysfunctions and paraphilic disorders.

Why is it important as psychologists to be accepting of transgender people?

We have a responsibility to do no harm

Know the stats on relationship between being transgender and risk

• Clark et al. 2014 (8,166 students; 1.2% trans): 20% attempted suicide and 46% self-harmed in past 12 months.

  • Veale et al. 2019 (1,178 trans people): >half suicidal thoughts past year, 79% ever; >1/3 lifetime attempt, 12% past-year attempt; 42% self-harmed past year (esp. trans men).

  • Treharne et al. 2020: ~2x as likely to have recently attempted vs cisgender; discrimination and lower social support more associated with risk.

  • Haas et al. 2014: TGD suicide rate up to 42-46%.

AKA - transgender people at disproportionate risk for suicide and self-harm, with social support being a large factor in mitigating this risk

Why is it important to ask about sex and sex-related ideas as a psychologist?

Sexual health = essential aspect of well-being

Very common, but many people will not bring up these problems if not asked

Bidirectional relationship between sex and psychopathology, where psychopathology can influence sexual well-being and sexual dysfunction may contribute to psychiatric symptomology— for ex., depression and erectile dysfunction

Higher psychopathology related to minority stress models for LGBT+ people: implications for risk

Paraphilic interests have risk implications

How does sex relate to media?

Fantasy sex vs real sex creates a mismatch between expectations and reality, influencing relational well-being

• Sex therapy response of “good enough sex” puts intimacy at the focus for mutual emotional acceptance

Media has influences on sexual preferences (for ex., anal sex has become more popular with rise of pornography, as has aggressive sex)

Easy to fall into “deviant” sexual preferences through media algorithms and reinforcement cycles (“One click away from deviance”)

Porn might mediate relationship between childhood trauma and paraphilic arousal

What psychopathologies are at increased risk in LGBT+ populations?

Depression

Anxiety

Drug and alcohol use and abuse

Adjustment disorders

Eating disorders

Suicidal ideation and attempts

What are reasons for higher rates of psychopathology in queer populations?

Not intrapersonal but interpersonal

Minority stress

Marginalisation/discrimination

Visible difference

Isolation & difference from family

Keeping secrets

Subcultural factors: for many, bars, hook ups, etc., represent places of safety and connection

What are small gender differences between men and women in sexual behavior?

Men:

• Think more about sex and want more sex

• Masturbate more

• Use internet pornography more

• Want more and have more partners

• Have more sexual dysfunction as they age

• Males have fewer negative core beliefs about sex

• More likely to emphasise dominance and aggression

Women:

• Desire for sex more often linked to social and relationship status

• More likely to value experience of passionate, romantic feelings

• Tend to be more ashamed of appearance flaws

• At all ages, more likely to report sexual dysfunction

• Objectively measured genital congestion is poorly associated with subjective mental excitement

What is Masters & Johnson’s model of the sexual response cycle?

Sex goes in a cycle of:

Desire (Urges in response to cues, fantasies) →

Arousal (subjective sense of sexual pleasure) →

Plateau phase (period before orgasm) →

Orgasm (ejaculation or contractions) →

Resolution (decrease in arousal)

What were criticisms of the sexual response cycle from Master's and Johnson? What was the response?

That it was not as applicable to women due to differences in spontaneous desire. Basson created an intimacy based model.

What is Basson’s Sexual Response Cycle model?

Motivations for sex → Sexual stimuli → Context and mind → Sexual arousal → responsive desire → satisfaction

Spontaneous desire can feed into motivations for sex, sexual stimuli, and sexual arousal.

I.e., acknowledging that desire to have sex can come from other factors other than spontaneous sexual desire

What is the Dual Control Model of Sexual Response?

There is an accelerator or Sexual Excitation System (SES) and a breaks or sexual inhibition system (SIS)

Accelerator: Receives info from environment and sends signals genitals to turn on. I.e., What turns you on

The brakes: Scanning for info from environment that is a good reason to not be turned on at the moment. Can be external (consequences) and internal (negative feelings about one’s body, performance failure). I.e., what turns you off

What is criteria for all sexual dysfunctions?

Must be present for 6+ months

Must lead to impairment or distress

Categories of sexual dysfunction by type in men and women

Desire: male hypoactive sexual desire disorder | female sexual interest/arousal disorder.

• Arousal: erectile disorder | female sexual interest/arousal disorder.

• Orgasm: delayed ejaculation, premature (early) ejaculation | female orgasmic disorder.

• Pain: (none) | genito-pelvic pain/penetration disorder.

Male Hypoactive Sexual Desire disorder

Little or no interest in any type of sexual activity; masturbation, fantasies and intercourse are rare.

• Accounts for half of all complaints at sexuality clinics; affects ~5% of men.

Differentiated from asexuality: Reflects a change over time

Erectile disorder

• Difficulty achieving or maintaining an erection; sexual desire usually intact.

• Most common problem for which men seek treatment.

• ~40% of men in their 40s have some impairment; prevalence rises with age (60% of men over 60

Female sexual interest/arousal disorder

Lack of or significantly reduced sexual interest/arousal, typically: reduced interest, reduced activity, fewer sexual thoughts, reduced arousal to cues, reduced pleasure/sensations during almost all encounters.

• ~22% of US women have low sexual interest; up to 43% in a large international survey (Laumann et al., 2005).

Female orgasmic disorder

Marked delay, absence or decreased intensity of orgasm in almost all encounters; not explained by relationship distress or other significant stressors.

1 in 4 women has significant difficulty; almost 90% are orgasmic with direct/indirect stimulation but most do not experience orgasm from just sexual intercourse

~75-80% never orgasm from intercourse alone.

Persistent genital arousal disorder

• NOT in DSM-5 or ICD-11. Unwanted, unremitting sensations of genital arousal with significant negative psychosocial impact (emotional lability, catastrophisation, suicidal ideation).

• Prevalence 0.6-3%. Diverse biopsychosocial contributors; common neurological basis: spontaneous intense activity in the genito-pelvic region of the somatosensory cortex.

Premature (early) ejaculation and delayed ejaculation

• Premature: ejaculation within ~1 minute of penetration and before desired; most prevalent male dysfunction (21% of adult males); most common in young, inexperienced men and declines with age.

• Delayed ejaculation: ~8% of men, rarely seek treatment.

Genito-pelvic pain/penetration disorder

Both sexes (rare in men). Females: difficulty with penetration plus pain, fear/anxiety about pain, or tensing of pelvic floor muscles in anticipation.

• 29% of women aged 18-29 reported pain during intercourse in the past 12 months.

• Dyspareunia = painful intercourse; vulvodynia = chronic vulval pain; vaginismus = spasm of muscles in the outer third of the vagina.

BIoloigcal causes of sexual dysfunction

Physical disease/chronic illness

Prescription medications (e.g. antihypertensives)

Ageing (hormonal changes)

Alcohol and drugs

Untreated STIs.

Post-SSRI sexual dysfunction (PSSD).

Psychological contributions to sexual dysfunction

Anxiety and negative thoughts about sexual encounters

Actively avoiding awareness of sexual cues (distraction)

Traumatic experiences

Body image

Mental illness

Spectatoring

Lack of familiarity with one's own genital anatomy.

Social and cultural contributors to sexual dysfunction

Erotophobia (sexuality associated with negative feelings, anxiety or threat); unpleasant/traumatic sexual experiences.

Poor interpersonal relationships; lack of communication.

Sexual scripts - social/cultural expectations that guide behaviour.

What are predisposing factors for sexual dysfunction?

Restrictive upbringing

Disturbed family relations

Traumatic early sexual experiences

Poor sex education

How does anxiety relate to sexual arousal?

Anxiety can increase alongside arousal

• SHock threats demonstrate that higher arousal/anxiety, greater erectile circumference

What makes the difference between dysfunctional performance and functional performance, even if both conditions have increased autonomic arousal?

Pre-emptive factors (i.e., negative affect vs positive; attentional focus on performance rather than erotic cues) and post arousal factors (increasingly efficient attentional focus)