Chapter 13: Sexual Problems and Therapy

Individual Differences and Relationship Conflicts - Expectations for Men

goal-oriented

Individual Differences and Relationship Conflicts - Expectations for Women

partner-oriented

with masturbation, men use ___ approach while women use ---

1 approach

different techniques

Relationship conflicts

Many couples (50%) have had, or eventually will have, sexual problems at some time in their relationship

Relationship solutions

\
* Working together and talking about differences
* Choosing properly trained and certified Marriage and Family Therapist

Sexual Therapy Techniques - Medical History

possible organic causes

Sexual Therapy Techniques - Sexual History

attitudes, behaviors, and partner reactions and involvement

Four types of sexual therapy

1. psychoanalysis
2. medical model
3. cognitive-behavior therapy
4. biopsychosocial approach

Psychoanalysis therapy

Long-term, intensive exploration of childhood causes for adult problems. Not commonly used today.

cognitive-behavioral therapy

Short-term, focusing on attitudes, beliefs and how they affect our behaviors.

psychosexual therapy

Insight into causes of the problems; successful with sexual aversion and low sexual desire.

medical model therapy

Looking for and treating organic causes for sexual problems

Sexuality __educator__

Teaches and trains about a range of topics related to sexual health, anatomy, etc

Sexuality __counselor__

Variety of professions ranging from medicine to clergy

sex __therapist__

Licensed mental health professions

ICD-10 Sexual Disorder

a clinically recognizable set of symptoms or behavior associated ... with distress and with interference with personal functions

APA Sexual Disorder

A heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure

Sexual problem criteria

1. one time occurrence
2. stress of life
3. common
4. most have problem at some point
5. problem with firsts
6. communication can help if it’s couple-related

Sexual disorder criteria

1. if the individual considers it to be one
2. some amounts of time (usually at least 6 months)
3. not the result of some other personal or interpersonal problem (depression)
4. issue occurs majority of the time

two views of dysfunction

1. medical
2. psychological

According to the DSM-5, Male Erectile Disorder will manifest at least one of three symptoms 75% to 100% of the time during sexual activity:

* Marked difficulty in obtaining an erection during sexual activity
* Marked difficulty in maintaining an erection until the completion of sexual activity
* Marked decrease in erection rigidity
* Persisted for approximately at least 6 months
* Cause clinically significant distress in the individual

Medicalization of sexuality with viagra

originally used to treat heart issues, realized giving erection, now used for ED

sexual health

* a state of physical, emotional, mental, and social well-being in relation to sexuality
* positive and respectful approach to sexuality
* free from coercion, discrimination, and violence

feelings toward ___ can affect sexual health

* body
* sexual anatomy
* expression of sexual feelings
* orgasm
* masturbation
* sexual intercourse
* desire, arousal

Sexual problems you have heard from college students - ==Women==

1. hard time orgasming
2. pain - lack of lubrication
3. inexperience

Sexual problems you have heard from college students - ^^Men^^

1. Ejaculating too quickly - No lube
2. Inexperienced
3. No clit knowledge
4. No condom knowledge
5. Alcohol and erections
6. Erection

Sexual disorders in ^^men^^

1. hypoactive sexual desire
2. erectile disorder
3. premature ejaculation
4. male orgasmic disorder
5. sexual pain disorder

Sexual disorders in ==women==

1. Female Sexual Interest/Arousal Disorder
2. Female Orgasmic Disorder
3. Sexual Pain Disorders

causes of sexual disorders

1. organic/medical
2. psychological
3. sociocultural (relationship)

hypoactive sexual desire (lack of interest for 6 months)

1. primary: never had sexual interest
2. secondary or acquired

\
* **causes**: organic (low T) or psychological (more common)
* **treatment**: common reason for entering therapy but difficult to treat
* medical vs biopsychosocial model

Causes of erectile dysfunction

1. 80% are physical, do REM sleep test


1. circulatory problems, neurological disorders, prostrate surgery, low T, groin injuries
2. 25% due to medications prescribed for other conditions (antidepressants and beta-blockers)
3. Smokers and drinkers
4. being overweight

What is erectile dysfunction?

* persistent or recurrent inability to get or maintain erection adequate for satisfactory sexual performance
* APA diagnostic criteria includes persistent (6months or more), causing distress or interpersonal relationship problems

nocturnal penile tumescence test

* measures force and duration
* several nights

sensate focus

* non-demand mutual pleasure technique
* couple learns how to touch and be touched
* without worrying about performing or reaching a goal

premature ejaculation

* Absence of reasonable voluntary control of ejaculation resulting in personal distress
* Organic or psychological causes

solutions to premature ejaculation

1. masturbating several hours before intercourse
2. pause-squeeze technique
3. pelvic floor exercises
4. condoms or analgesic cream to reduce stimulation
5. other medications
6. counseling

male orgasmic disorder

* delay or absence of orgasm following what is typically a normal sexual excitation phase
* most common causes are psychological (fear, guilt, etc.)

bridge manuever

man masturbates alone and w/partner; partner stimulates to orgasm then quickly puts penis into vagina

dyspareunia

* infections
* peyronie’s disease

priapism

prolonged erection

benign coital cephalalgia

sex headache at start/after orgasm, usually in men

Four categories of sexual problems in ==women==

1. sociocultural, political, economic factors
2. partner and relationship factors
3. psychological factors
4. medical factors

sexual interest/arousal disorder (most common for women)

* persistent or recurrent deficiency of sexual fantasies/thoughts and/or desire for or receptivity to sexual activity, which causes personal distress
* 1/3 women

sexual aversion disorder

* more severe
* not in DSM-5

psychological and/or organic causes (women)

Sexually repressive upbringing, past sexual traumas, depression, some medications (esp. antidepressants), low testosterone (not common),coexisting sexual problem (such as painful coitus)

relationship issues (women)

Betrayal, dislike, fear of partner, partner’s abuse, partner’s negative patterns of communication, insufficient emotional intimacy

Treatments for desire

* most difficult to treat and lowest success rate
* self-help
* communication, sex goals, novelty, non-sexual intimacy

self-expansion

* broadening sense of self with your partner
* engaging in new activity (going to a lecture, new site, exploring something new)

persistent sexual arousal disorder

* Characterized by unrelenting, spontaneous, and uncontainable genital arousal, mostly in females.
* Can experience spontaneous orgasms that do not resolve arousal. The person's arousal is not linked to sexual desire.
* Can lead to on going physical pain, stress, and psychological difficulties due to an inability to carry out everyday tasks.
* Sexual syndrome that takes joy out of life

Female orgasmic disorder

* persistent or recurrent inability of a woman to have an orgasm (climax or sexual release) after adequate sexual arousal, and sexual stimulation, which causes personal distress
* Associated with older women, less assertive women, can be primary, secondary, or situational (partner-or action based)
* Only half of women are distressed by failure to orgasm

genito-pelvic pain/penetration disorders

1. dyspareunia (pain during sex)
2. vaginismus (involuntary spasms of muscles surrounding vagina cause full/partial closure)
3. noncoital pain disorder

postcoital dysphoria

* sadness, irritability, and anxiety after sex
* 33% women, 12-34% men

Cross-cultural perspectives on sexual therapy

* western, middle-class values
* sex for physical pleasure
* men and women are equal partners

Northern Africa and Middle East sexual attitudes

restrictive, patriarchal, sexual attitudes

Latin countries sexual attitudes

male-oriented sexual regimehi

Hindu and Buddhist sexual attitudes

emphasize unity, harmony, and spiritual growth

female genital mutilation

* any procedure involving partial removal or total removal or deliberate injury to the female genitals for non-medial reasons
* NO HEALTH BENEFITS
* CULTUAL CUSTOM based on limiting female sexual behavior
* illegal in the US still routinely performed in some African countries

Where does FGM occur?

* 300 million women
* 0-4 years, almost always before 15 years
* 1/2 population live in Indonesia, Egypt, and Ethiopia
* 84.5% report complications

hypersexuality

* No DSM-5 category
* Sexual compulsion aka sexual addiction
* Recurrent failure to control the behavior and/or continuation of behavior despite significant harmful consequences
* Engage in sex (or masturbation) compulsively to reduce anxiety; usually finding little or no emotional satisfaction

compulsive sexual behavior

* a disorder in which the individual experiences intense sexually arousing fantasies, urges, and associated sexual behavior
* Not in DSM – 5
* 3-5% - hypersexuality
* 3% - 20 or more hours per week online sex


* ICD – 11 (International Classification of Diseases)
* Classified as an impulse control behavior like gambling and kleptomania

Types of treatment

* therapy
* cognitive behavioral therapy
* acceptance and commitment therapy
* medications
* support groups
* 12 step programs
* sex addicts anonymous
* sexaholics anonymous
* NoFap - online community

Porn addiction

* An addiction model of compulsive sexual activity with concurrent use of pornographic material, despite negative consequences to one's physical, mental, social, or financial well-being.
* Neither the DSM-5 nor the ICD-11 classify pornography as a mental disorder or addiction.

problematic internet pornography viewing

viewing of Internet pornography that is problematic for an individual due to personal or social reasons, including excessive time spent viewing pornography instead of interacting with others.

sexual dysfunction in younger men ( < 40Y)

* Sharp increase
* 10 – 20% organic
* More often psychological


* Increased rise in ED, orgasmic disorder, low sexual arousal
* Porn-Induced Erectile Dysfunction

gender differences in porn (==women==)

* often watch with partner
* watch soft porn; couples porn
* report higher levels of intimacy

gender differences in porn (^^men^^)

* often watch alone
* watch sex acts without context
* report lower levels of intimacy

associative learning

* When a user has conditioned his sexual arousal to Internet pornography, sex with desired real partners may register as “not meeting expectations” (negative reward prediction) resulting in a corresponding decline in dopamine.
* Combined with the inability to click to more stimulation, this unmet prediction may reinforce an impression that partnered sex is less salient than Internet pornography use.
* It is possible that if a susceptible Internet pornography user reinforces the association between arousal and watching other people have sex on screens while he is highly aroused, his association between arousal and real-life partnered sexual encounters may weaken.

Treatments by Many Different Types of Professionals

* medical doctors
* family practitioners
* OB-GYNS


* psychotherapists
* marriage-family
* cognitive-behavioral
* sex therapists

O-shot

* Marketed as the orgasm shot, or O-Shot, treatment involves injecting the clitoris, labia, and G-spot with platelets — a substance in your blood that contains healing proteins called growth factors —extracted from your own blood.
* There’s currently very little research on the O-Shot, and no scientifically proven evidence that it can improve your sex life.

sex surrogate

* **A sex surrogate is a person who helps others over come social and sexual issues through hands-on intimacy**
* The surrogate engages with the client in a physical, intimate way to build their sexual confidence and make them more comfortable with emotional and physical intimacy
* The legal status of surrogate partners is undefined in most of the United States and most countries around the world, according to the IPSA. This means that there are generally no laws regulating the profession.

sex surrogacy experiment

* (1985), director Kirby Dick weaves a fascinating study of the curious role of a sex surrogate in the then-new discipline of sexual therapy.
* Maureen Sullivan and two of her clients agreed to have the entire progression of their therapy taped.
* Newly divorced man
* 25 year old grad student