ch 10 behavior disorders

what to consider for what is normal vs abnormal sexual behavior

• normative facts and stats

• cultural considerations

• gender differences in sexual behavior and attitudes

heterosexual behavior

sexual activity with members of the opposite gender

same sex sexual behavior

sexual activity with members of the same gender

nonbinary

refers to a spectrum of gender identities that are neither female nor male

sexual dysfunction

• sexual disorder in which the client finds it difficult to function adequately while having sex

  • 4 stages of sexual response cycle that are associated with specific sexual dysfunctions - desire, arousal, and orgasm, and pain (in women)

  • must be present for 6+ months to meet criteria for a diagnosis

  • must lead to impairment or distress to be considered a disorder

classification of sexual dysfunctions

• lifelong vs acquired

  • chronic condition that is present during a person’s entire sexual life

  • acquired - refers to a disorder that begins after sexual activity has been relatively norma

• generalized vs situational

  • generalized - occurring every time the individual attempts sex

  • situational - occurring with some partners or at certain times but not with other partners or at other times

• psychological factors alone

• psychological factors combined with medical condition

male hypoactive sexual desire disorder

• dysfunction in which a man feels distress from having little or no sexual interest

female sexual interest/arousal disorder

•  recurrent inability in some women to attain or maintain adequate lubrication and sexual excitement swelling responses until completion of sexual activity 

erectile disorder

recurring inability in some men to attain or maintain adequate penile erection until completion of sexual activity

• sexual desire is usually intact

• most common problem for which men seek treatment

• prevalence increases with age

delayed ejaculation

• disorder in which a man achieves orgasm only with great difficulty

  • Treatment rarely sougt

female orgasmic disorder

• recurring delay or absence of orgasm in some women following a normal sexual excitement phase, relative to their prior experience and current stimulation. Also known as inhibited orgasm (female)

  • Not explained by relationship distress or other significant stressors

premature ejaculation

• recurring ejaculation before the person wishes it, with minimal sexual stimulation

  • Defined as approx 1 min after penetration the DSM-5

  • Far more common male orgasmic disorder

  • Most prevalent sexual dysfunction in adult males (21% of all adult males)

genito-pelvic pain / penetration disorder

• sexual dysfunction in which a woman experiences pain or difficulty with penetration during intercourse; may include vaginismus

• in females, difficulty with vaginal penetration during intercourse, associated with one or more of the following:

  • Pain during sex or penetration attempts

  • fear/anxiety about pain during sexual activity 

  • Tensing of pelvic floor muscles in anticipation of sexual activity 

vulvodynia

• chronic pain in the area on the outside of women’s genitals (the vulva)

vaginismus

• recurring involuntary muscle spasms in the outer third of the vagina that interfere with sexual intercourse

three major aspects to assessment of sexual behavior

• Interviews 

• Thorough medical evaluation

  • medication side effects 

  • Physical conditions

• Psychophysiological assessment - to directly measure physiological aspects of sexual arousal

  • Males - penile strain gauge (measures erection)

  • Females - vaginal photoplethysmography (measures blood flow to the vagina

erotophobia

associate sexuality with negative feelings, anxiety, or threat

treatment of sexual dysfunction (education)

• Education alone can be surprisingly effective

• Masters and Johnson's psychosocial intervention

  • Education about sexual response, foreplay, etc.

  • Sensate focus and nondemand pleasuring

    • Sexual activity with the goal of focusing on sensations without trying to achieve orgasm

    • Decreases performance anxiety

treatment of sexual dysfunction (additional psychosocial procedures)

• Squeeze techniques - premature ejaculation

• Masturbatory training- female orgasm disorder

• Use of dilators - vaginismus (unwanted tightening of vaginal muscles)

• Exposure to erotic material - low sexual desire problem

treatment of sexual dysfunction (medical treatment of sexual dysfunction)

• Erectile dysfunction

  • Viagra and similar medications

  • Injection of vasodilating drugs into the penis

  • Testosterone

  • Penile prosthesis or implants

  • Vascular surgery

  • Vacuum device therapy

• few for females

paraphilic disorders

• sexual disorders and deviations in which sexual arousal occurs almost exclusively in the context of inappropriate objects or individuals

  • Often multiple paraphilic patterns of arousal 

  • High comorbidity with anxiety, mood, and substance use disorder**

Frotteuristic disorder

• - paraphilic disorder in which the person gains sexual gratification by rubbing against unwilling victims in crowds from which they cannot escape

• Fetishistic disorder

• - long-term, recurring, intense sexually arousing urges, fantasies, or behavior that involve the use of nonliving, unusual objects and that cause distress or impairment in life functioning

  • Attraction to nonhuman objects or highly specific focus on nongenital body part(s)

Voyeuristic disorder

• - a paraphilic disorder in which sexual arousal is derived from observing unsuspecting individuals undressing or naked

Exhibitionistic disorder

-  sexual gratification attained by exposing genitals to unsuspecting strangers

Transvestic disorder

• - a paraphilia in which individuals, usually males, are sexually aroused or receive gratification by wearing clothing of the opposite sex

Sexual sadism

• - paraphilia in which sexual arousal is associated with inflicting pain or humiliation

• Sexual masochism

• - paraphilia in which sexual arousal is associated with experiencing pain or humiliation

pedophilia

paraphilia involving strong sexual attraction toward children

• Vast majority are males

• Associated features

  • Incestuous males may be aroused by adult women

  • Male pedophiles are usually not aroused by adult women

  • Some try to rationalize the behavior

Incest

- deviant sexual attraction (pedophilia) directed toward a family member; often the attraction of a father toward a daughter who is maturing physically

Covert sensitization

• cognitive-behavioral intervention to reduce unwanted behaviors by having clients imagine the extremely aversive consequences of the behaviors and establish negative rather than positive associations with them

Orgasmic reconditioning

• learning procedure to help clients strengthen appropriate patterns of sexual arousal by pairing appropriate stimuli with the pleasurable sensations of masturbation

  • patients are instructed to masturbate to their usual fantasies but to substitute more desirable ones just before ejaculation

drugs treatment for paraphilic disorders

• Medications that reduce testosterone may be used in some like convicted sex offenders

• Most popular drug used to treat individuals with paraphilic disorders is an antiandrogen called cyproterone acetate

  • This drug eliminates sexual desire and fantasy by reducing testosterone levels dramatically, but fantasies and arousal return as soon as the drug is removed

• Second drug is medroxyprogestoreone

  • Hormonal agent that reduced testosterone

gender identity

• perception of being a man, a woman, gender fluid, nonbinary, or some other experience

• Usually formed between 18 to 36 months of age

• Not related to transvestic disorder or same sex attraction

gender dysphoria

• psychological dissatisfaction with biological gender, a disturbance in the sense of identity as a male or female. The primary goal is not sexual arousal but rather to live the life of the opposite gender

  • Diagnosis is relatively rare

    • More common in males (5 to 14 per 1000) versus females (2 to 3 per 1000)

  • Rates are similar across cultures

    • Some cultures revere individuals with nontraditional gender experience

  • No clear biological causes identified, but evidence of genetic influence

    • Studies have found that 60 to 70% of variance in gender expression is explained by genetics

    • Exposure to hormones in utero may play a role

gender noncomformity

• phenomenon in which pre-pubescent children do not identify with their biological sex, but instead identify strongly with the gender of the opposite sex and display varying degrees of behavior more characteristic of the opposite sex

treatment of gender dysphoria

• administration of hormones about secondary sex characteristics with identity

• gender affirming surgery

• psychosocial intervention to change gender identity - usually unsuccessful

gender affirming surgery

nonreversible altering of anatomy physically to be consistent with gender identity

t/f - there is always more variation within a group than between groups

true

sexual orientation

gender an individual is romantically attracted to

Key findings from Indiana university national survey of sexual health and behavior

• 7% of adult women and 8% of men identify as gay, lesbian, or bisexual

• the proportion of people in the US who have had same sex sexual interactions at some point in their lives is higher

• among people in relationships

  • 89% report monogamous partnerships

• people identifying as gay, lesbian, and bisexual were less likely to report monogamy and more likely to report open relationships and non-consensual non-monogamy

key findings from frederick et al (2018) with over 50000 adults

• Percent reporting that they usually or always orgasm during sex

  • Heterosexual men: 95%

  • Gay men: 89%

  • Bisexual men: 88%

  • Lesbian women: 86%

  • Bisexual women: 66%

  • Heterosexual women: 65%

• Women who orgasmed more frequently reported receiving more oral sex, having sex for longer durations, and being more satisfied with their relationships 

two most common reasons couples seek therapy

finances and sexual dissatisfaction

gender differences

• There are at least slight (though decreasing) gender differences in:

  • Acceptability of casual or premarital sex (men>women)

  • Number of sexual partners (men>women)

  • Rates of masturbation (men>women)

  • “Sexual self-schema” : women tend to be more embarrassed, conservative, self-conscious about sex

• No gender differences in:

  • Attitudes toward same-sex sexual behaviors (generally accepting)

  • Attitudes toward masturbation (generally accepting)

  • Views toward sexual satisfaction (important for both)

cultural differences

• Acceptability of premarital sex

• Acceptability of homosexuality

• Perceived importance of sex

• Reasons for sex (e.g., for personal pleasure)

• *note: most, if not all, of these cultural differences also differ for men versus women within a given culture

development of sexual orientation

• Interaction of bio-psycho- social influences

• Genes account for approximately 34-39% in men and 18% to 19% in women (so, stronger environmental influences in women)

  • Like almost everything, almost certainly involves multiple genes

• Environmental factors may include in utero hormone exposure

• Honestly, we know very little, including how fluid vs stable(sexual orientation) it may be across life (particularly adolescence into early adulthood)

disorders of sexual development

• Characterized by ambiguous genitalia with documented hormonal or other physical differences

• Surgery and hormonal replacement therapy has been standard treatment for many individuals with disorders of sexual development

  • However, wisdom of early surgical reconstruction of genitals is debateable