Sexology Lectures

Lonnie Barbach

made self-help books, and group therapy for women with orgasm problems (‘preorgasmic’). It was a lack of knowledge that was the cause of the lack of orgasms according to her.

Nature-nurture controversy

In the nature-nurture controversy there was an interesting case. There were twin boys who were both circumcised, but with one of them it went wrong. They then reconstructed the boy as a girl and raised her as one. This opened the discussion about the nurture part of gender. People believed at first that this had been a success. However, in the end David who lived as Brenda for fourteen years, heard from his parents that he was born as a boy. He always felt off and therefore wanted to change back as a guy and identifies as such in the end. He reconstructed his penis and it was a ‘failed’ experiment. Intersex children are hormonally imbalanced in the womb and it can show in the brain, therefore it does not mean that the surgery of intersex children would be a failure, it is just that David was not intersex, he was born as a boy.

Anatomy and physiology of sexual functioning in women

* Healthy sexual development comes from (1) matching gender identity, (2) a warm pedagogical climate, (3) positive examples of relational behaviour, (4) positive messages concerning sexuality and the own body, (5) the possibility to age-specific consensual sexual practice behaviour, (6) skin contact
* The appearance of external genitals determines the gender at birth, but gender identity is multifactorial
* The physiology during arousal involves: (1) increase in vaginal bloodflow, (2) swelling of the vulva, (3) elongation of the vagina and ballooning, (4) lubrication, (5) erection and retraction of the clitoris, (6) engorgement and rise of the uterus
* During arousal, peripheral responses include: an increase in heartbeat, increase in breathing, stiffness of nipples and sex bloss on the skin
* During orgasm one experiences an intense feeling of pleasure, there can be some degree of altered consciousness, specific sensations in the genital region and pelvis, muscle contractions in the pelvic floor and other rhythmic movements

MRKH syndrome (Mayer-Rokitansky Kuster Hauser syndrome)

46XX chromosomes, uterus and vagina are not developed, no menstruation, ovaries are still there but no secondary sex characteristics, no intercourse or pregnancy possible

Acquired abnormal anatomy

myoma, ovarian cyst, vulvar carcinoma

Female genital cutting (genital mutilation)

done in Africa, the Middle East and Asia. Reasons include sociocultural factors but it is not related to religion. It is connected with views on cleanliness, beauty, femininity and sexual morality. Performed on the age of 4-12 years.

Abnormal chromosomal pattern → Turner syndrome (XO)

underdevelopment of gonads, no secondary sex characteristics, not fertile, no eggs or less eggs

Female only genetic disorder

Disorder of sexual development (DSD) → AIS

46XY chromosomes, but the person is still female. Has male gonads and a male hormone profile but external genitals are female. No armpit or pubic hair, no menstruation, infertile.

Adrenogenital syndrome in women (AGS)

46XX chromosomes, internal genitals female, has clitoris hyperplasia which means that the clitoris looks like a penis, high testosterone levels

Anatomy and sexual functioning in males

* Hypothalamus regulates the release of several hormones that contribute to sexual functioning: noradrenaline/adrenaline (fight or flight), cortisol (stress), testosterone (motivator), dopamine (pleasure and wellbeing), serotonin (obsession), oxytocin (bonding, attraction, arousal)
* Sexual desire is inhibited by serotonin, prolactin and opioids
* Excitatory factors contributing to sexual desire are testosterone, estrogen, progesterone and dopamine

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* There are three different types of erections:


1. **Psychogenic erections**– triggered by sensory, visual and auditory stimuli, or fantasies, which influence sacral centres and creates an erection through the hypogastric center
2. **Reflexogenic erections**– direct genital stimulation leads to an erection
3. **Nocturnal erections**– reflexogenic during REM sleep

* The enemies of an erection are smoking, alcohol, drugs, stress and obesity
* The pelvic floor is an important contributor to erection and ejaculation because it enhances blood flow in ischiocavernous muscle to facilitate erection and in bulbocavernous to maintain an erection. The pelvic floor also inhibits ejaculation by the relaxation of the bolbucavernous and ischiocavernous muscles.

Sexual abuse

unwanted sexual activities such as exposure to public masturbation, genital touching, or attempted or complete oral, vaginal, or anal intercourse

* Childhood sexual abuse: before the age of 16
* Sexual abuse is often classified on a scale reflecting its severity from non-contact → contact → contact with penetration (and frequency)


* The majority of perpetrators are male (94%) and mostly the perpetrator was known (83%)
* Before the age of 16, the perpetrator was most often from the neighbourhood, a family member (other than father or brother), or (ex-)boyfriend
* After the age of 16, the perpetrator was most often (ex-) partner, acquaintance from nightlife or a friend
* Non-consensual sexual stimulation during a sexual assault can lead to sexual arousal (for example lubrication) and it can cause shame and guilt in women
* Treatment for PTSD caused by sexual abuse:

Psychological treatment

* Cognitive Behavioural Therapy
* Prolonged and Narrative Exposure
* Eye Movement De-sensitisation Reprocessing (EMDR) Pharmacological treatment (as an addition)
* SSRIs (depression)

The treatment focuses on:

* reducing anxiety and fear
* restructuring cognitions about the situation and own role
* reducing feelings of guilt and shame
* discovery of one's body
* setting boundaries
* time on psychosexual education

Sexology research

* Issues in psychophysiological sex research: objective assessment (cause and effect), small samples lead to selection bias, ethical questions (sex is a private subject)
* Possibilities for research
* studying the effect of drugs, disease and surgery
* looking at the differences between individuals with and without sexual dysfunction
* relationship between genital response and sexual feelings
* underlying mechanisms of sexual desire, arousal and organisms and studying the disorders of these
* There is an automatic response to sexual stimuli, an increase in blood flow even if the people report that they are not aroused
* Even if people perceive sexual stimuli unconsciously it increases emotional-motivation systems in the brain and leads to an increase in dopamine, therefore also an increase in arousal
* Correlations between genital and subjective sexual arousal are low in women but high in men
* After men and women watched two erotic films (one was male-oriented and the other was female-oriented) there was no difference in the genital response
* For subjective sexual response: men had equally strong sexual feelings for both films, women had stronger sexual feelings for the woman-oriented film
* In conclusion, in women, the genital response does not predict sexual feelings, sexual feelings are determined more by meanings associated with the stimulus context
* In men, sexual feelings are determined more by the intensity of genital response
* Implications about unconscious activation:
* the motivation process has already been activated before the individual is conscious of this
* helps in understanding why sexual responses can be difficult to control (hypersexuality)
* Implications about the relationship between genital-subjective arousal:
* the automatic genital response is not evidence of a positive sexual experience
* complaints of reduced sexual arousal do not indicate disturbed genital response
* meaning of the stimulus and the context are really important for women's sexual feelings
* pharmacological treatment aimed at increasing the genital response is an option for men but not for most women

Sexual Dysfunction in women

* Prevalence of sexual interest and arousal problems in women
* lack of sexual desire: 20-30%
* sexual arousal problems: 11-31%
* when sexual distress is included as a criterion: a decrease of 50%
* high co-morbidity of desire and arousal problems
* 3.5-35% of women have problems reaching orgasm
* women experience more pain during sex compared to men: 15% of women and 3% of men

Sexual Disorders in Men

* Criteria for the DSM: *must cause significant distress, must occur on 75-100% of occasions, minimum duration of 6 months, and it cannot be attributed to a different disorder, severe relationship stress, or the effects of medication/substance.*
* **Sexual response requires:** adequate sexual stimulus, genital response (subjective experience of arousal), situational factors (context, opportunities, and motivation), and physiological sensitivity (androgenic hormones, neurotransmitters etc.)
* Testosterone: a minimal amount is required to function sexually, testosterone makes the system ready for sexual activity, it happens often in 65+ (20%)
* **Diagnosis:**


* Physical examination and lab tests
* Individual’s history (anamnesis), focusing on: psychiatric co-morbidity, negative sexual experiences, interest in sexual stimuli, relational factors, use of alcohol and drugs (lifestyle), and what is the situation regarding ‘sexual motivation’
* In sex counselling there is also a focus on life-style changes: weight loss and exercise, as well as breaking the pattern of avoidance behavior by looking for sexual cues (like porn) and doing sensate focus exercises.


* **Social/cultural and relational factors in ED**: “Erotophobia”: learned negative attitudes towards sexuality, traditional religious beliefs, poor interpersonal relationships and communication
* **Premature ejaculation**: Mild: ejaculation within 30 seconds to 1 minute after penetration, Moderate: ejaculation within 15 – 30 seconds after penetration, severe: ejaculation within 15 seconds after penetration
* **Sexual aversion disorder**: Persistent or recurrent extreme aversion for, and avoidance of, all or almost all genital sexual contact with a partner. Inhibition of sexual desire due to:


* Negative sexual experience(s) (sexual abuse)
* Negative views about sexuality
* Negative sensations during sexual activities


* **Other factors related to hyperactive sexual desire**: alcohol/drug abuse, side effect of dopaminergic anti-Parkinson’s disease medication, manic episode in a bipolar disorder, neurobiological like having Alzheimer’s, and an obsessive-compulsive behavior pattern (as described in the chapter).
* **Penis enlargements**: half of the men are dissatisfied with the surgery after asking them after three years, there is no correlation between penis size and sexual satisfaction. For many of the men it is a case of body dysmorphic disorder, in which they cannot stop thinking about their flaw even though it is not or barely visible to others. Most men experiencing this actually have a normal sized penis.

Gender Dysphoria

er Dysphoria

* **Sex** refers to the physical aspects of biological sex. Refers to chromosomes and physical anatomy of a person
* **Gender** is the way someone identifies. It contains psychosocial aspects like gender role, gender expression etc. Gender is a social construct
* **Gender role** refers to the behaviour, interests and preferences that in a specific culture and period of time are perceived as more typical male or female
* **Gender identity** is the subjective feeling to belong to one of the two (male/female) or an alternative gender
* **Gender spectrum** refers to the fact that recently there has been a shift from binary to variation and shift from pathology to diversity
* According to the The DSM-5 the diagnosis of gender dysphoria in adolescents or adults can be made if:


* Two or more of the following criteria are experienced for at least six months:
* A significant incongruence between one's experienced or expressed gender and one's sexual characteristics
* A strong desire to be rid of one's sexual characteristics due to incongruence with one's experienced or expressed gender
* A strong desire for the sexual characteristics of a gender other than one's assigned gender
* A strong desire to be of a gender other than one's assigned gender
* A strong desire to be treated as a gender other than one's assigned gender
* A strong conviction that one has the typical reactions and feelings of a gender other than one's assigned gender
* The condition must be associated with clinically significant distress or impairment

Paraphilias, Fetishes and Other Sexual Variations

* Paraphilias and fetishes mainly have three categories: 1) unusual/bizarre, 2) potentially dangerous but legal, 3) illegal
* Examples in the category of unusual/bizarre: foot fetish, rubber fetish, hair fetish, urophilia, BDSM and partialism
* Examples in the category potentially dangerous but legal: voyeurism, some extreme aspects of BDSM, paedophilia (only the urges but not acts)
* Examples in the category of illegal: exhibitionism, paedophilia in combination with child sex abuse, zoophilia, necrophilia

**Paedophilic Paraphilic Disorder** according to the DSM 5

* A: The individual experiences intense sexually arousing fantasies or urges involving sexual activity with prepubescent children (under the age 13)

o (activity = masturbation)

* B: The individual has acted on these urges, or the urges have caused serious distress
* C: The individual is at least 16 years of age and at least 5 years older than the victim (excluding two adolescence with 5 years age difference)


* could be exclusive or non-exclusive
* restricted or not restricted to incest

**Female Sexual Pain Disorders**

* **Lifelong (or primary) vaginismus** is the inability to have sexual intercourse, despite the wish and attempts to do so. The somatic cause has to be excluded. Vaginismus is lifelong if the woman has never been able to have intercourse.


* Vaginismus is not a pelvic floor dysfunction
* The catastrophic thought a woman might have about the intercourse (“it will be very painful”) lead to fear and therefore to avoidance
* CBT is a good treatment option for vaginismus
* Psychoeducation about pain, fear and muscle tension, anatomy and female sexual response
* Explaining different relaxation exercises for the pelvic floor
* Some gradual exposure exercises like penetration in small steps (fingers for example)
* (Sexual) communication with partner in relationship
* Search for new pleasurable activities


* **Genito-Pelvic Pain/Penetration Disorder: Persistent or recurrent difficulties with at least one of the following: vaginal penetration/intercourse, vaginal or pelvic pain during penetration, fear or anxiety about pain in anticipation of or during vaginal penetration, tightening or tensing of the pelvic floor muscles during attempted penetaration**


* Must cause significant distress and occur on 70-100% of occasions
* Minimum duration of 6 months

The main contribution of Kinsey

the report of his research on sexual behavior in men and women

SSRI (serotonin reuptake inhibitors)

Delay orgasm & ejaculation

Oxytocin

Pair bonding & lactation

Question

Women seem to vary in the extent of testosterone affecting their sexuality

Sexual desire → estrogen, testosterone, progesterone

Premature ejaculation/ therapy

Antidepressants

Real life testing

Present themselves in their desired gender & will usually start hormone therapy