• Relatively little is known about racial and cultural differences in sexuality

Sexual Dysfunctions

• Sexual Dysfunction: A disorder marked by a persistent inability to function normally in some area of the sexual response cycle

• As many as 30% of men and 45% of women around the world suffer from such a dysfunction during their lives

• People have problems with their sexual responses

• Typically very distressing

• Often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems

• Dysfunctions are often interrelated

• Human sexual response is a cycle: desire, excitement, orgasm, and resolution

  • Sexual dysfunctions affect one or more of the first three phases

• Lifelong Type Sexual Dysfunction: People struggle with a sexual dysfunction their whole lives

• Acquired Type Sexual Dysfunction: Normal sexual functioning preceded the dysfunction

• Generalized Type Sexual Dysfunction: The dysfunction is present during all sexual situations

• Situational Type Sexual Dysfunction: The dysfunction is tied to particular situations

Disorders of Desire

• Desire Phase: The phase of the sexual response cycle consisting of an urge to have sex, sexual fantasies, and sexual attraction to others

• Male hypoactive sexual desire disorder

  • Men persistently lack or have reduced interest in sex and engage in little sexual activity

  • When they do have sex, their physical responses may be normal and they may enjoy the experience

  • As many as 18 percent of men worldwide have this disorder

  • The number seeking therapy has increased during the past decade

• Female sexual interest/arousal disorder

  • Women lack normal interest in sex and rarely initiate sexual activity

  • Feel little excitement during sexual activity, are unaroused by erotic cues, and have few genital or nongenital sensations during sexual activity

  • 39% of women worldwide have reduced sexual interest and arousal

  • ½ of those individuals feel significant distress due to their level of arousal, so they qualify for this disorder

  • Can also be separate dysfunctions: female hypoactive sexual desire disorder and female sexual arousal disorder

  • Sex drive is determined by a combination of biological, psychological, and sociocultural factors

• Biological causes of low sexual desire

  • Abnormalities in hormonal activity can lower a person’s sex drive

  • High levels of prolactin, low levels of testosterone, and abnormal level of estrogen can lead to low sex drive

  • Low sexual desire may be linked to excessive activity of serotonin and dopamine

  • Sex drive can be lowered by certain pain meds, psychotropic drugs, and illegal drugs

  • Low levels of arousal may enhance the sex drive by lowering a person’s inhibitions

  • Long-term physical illness can also lower a person’s sex drive

• Psychological causes of low sexual desire

  • A general increase in anxiety, depression, or anger may reduce sexual desire

  • People with low sexual desire have particular attitudes, fears, or memories that contribute to their dysfunction

    • A belief that sex is immoral or dangerous

    • A fear of losing control over their sexual urges

    • A fear of pregnancy

  • Certain psychological disorders may also contribute to low sexual desire

    • Mild level of depression

    • People with OCD find contact with other people’s body fluids and odors to be highly unpleasant

• Sociocultural causes of low sexual desire

  • Situational pressures (divorce, death in the family, job stress, etc.)

  • Among women, the best predictors of sexual dysfunction are her level of emotional well-being and the quality of her relationship with her partner

• Cultural standards

  • Some men can’t feel sexual desire for a woman they love and respect

  • Our society equates sexual attractiveness with youthfulness

• Trauma of sexual molestation or assault is especially likely to produce the fears, attitudes, and memories found in disorders of sexual desire

  • Some survivors of sexual abuse may feel repelled by sex

  • Some survivors may have vivid flashbacks of the assault during consensual activity

Disorders of Excitement

• Excitement Phase: The phase of the sexual response cycle marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing

• Men - blood pools in the pelvis and leads to erection of the penis

• Women - produces swelling of the clitoris and labia, as well as lubrication of the vagina

• Female Sexual Interest / Arousal Disorder

  • May include dysfunction during the excitement phase

• Erectile Disorder

  • Men persistently fail to attain or maintain an erection during sexual activity

  • Occurs in 15-25% of the male population

  • Most men with this disorder are over the age of 50

  • Half of all adult men experience erectile difficulty during intercourse at least some of the time

  • Biological causes

    • The same hormonal imbalances that can cause male hypoactive sexual desire disorder can also produce erectile disorder

    • Vascular problems: Problems with the body’s blood vessels

      • Any condition that reduces blood flow to the penis may lead to erectile disorder

    • Damage to the nervous system

    • The use of certain medications and various forms of substance abuse may interfere with erections

    • Medical procedures have been developed for diagnosing biological causes of erectile disorder

    • Abnormal or absent nightly erections usually (but not always) indicates some physical basis for erectile failure

      • Nocturnal Penile Tumescence: Measure of erections during sleep

      • Men typically have erections during REM sleep and have 2-5 REM periods each night

      • Rough screening device - A patient fastens a snap gauge band around his penis before going to sleep

        • Broken band indicates an erection during the night

        • Unbroken band indicates no nighttime erections and suggests that his erectile problem have have a physical basis

  • Psychological Causes

    • 90% of all men with severe depression experience some degree of erectile dysfunction

    • Cognitive-Behavioral Theory: Once a man begins to have erectile problems, he becomes fearful about failing to have an erection and worries during each sexual encounter, taking on a spectator role that becomes the reason for the ongoing problem

    • Spectator Role: A state of mind that some people experience during sex, focusing on their sexual performance to such an extent that their performance and their enjoyment are reduced

      • Happy Orgasming - Only_A_Fangirl

  • Sociocultural Causes

    • Financial stress

    • Martial stress

      • Wife provides too little physical stimulation for her aging husband

      • Couple believes that only intercourse can give the wife an orgasm, which increases the pressure on the man and makes him more vulnerable

Disorders of Orgasm

• Orgasm Phase: The phase of the sexual response cycle during which a person’s sexual pleasure peaks and sexual tension is released as muscles in the pelvic region contract rhythmically

• Early Ejaculation: A dysfunction in which a man persistently reaches orgasm and ejaculates within 1 minute of beginning sexual activity with a partner and before he wishes to

  • As many as 30% of men worldwide ejaculate early at some time

  • Many young men have this dysfunction, but men of any age may suffer from it

  • Young men often ejaculate prematurely during their first sexual encounter

  • With continued sexual experience, most men acquire more control of their sexual responses

  • Men of any age who have sex only occasionally are also prone to ejaculate early

  • Premature ejaculation may be related to anxiety, hurried masturbation experiences during adolescence, or poor recognition of one’s own sexual arousal

  • Biological Factors

    • Some men are born with a genetic predisposition to develop this dysfunction

    • Brains of men who ejaculate prematurely contain certain serotonin receptors that are overactive and others that are underactive

    • Men with this dysfunction have greater sensitivity or nerve conduction in the area of their penis

• Delayed Ejaculation

  • A man with delayed ejaculation persistently is unable to ejaculate or has very delayed ejaculations during sexual activity with a partner

  • As many as 10% of men worldwide have this disorder

  • Low testosterone level, certain neurological diseases, and some head or spinal cord injuries can interfere with ejaculation

  • Substances that slow down the sympathetic nervous system can affect ejaculation

  • Performance anxiety, spectator role, cognitive-behavioral factors

  • Past masturbation habits - may have difficulty reaching orgasm in the absence of the sensations tied to objects used in masturbation

  • Delayed ejaculation may develop out of male hypoactive sexual desire disorder

    • A man who engages in sex without any real desire for it may not get aroused enough to ejaculate

• Female Orgasmic Disorder

  • Women persistently fail to reach orgasm, have very low intensity orgasms, or have a very delayed orgasm

    • Every Day, a Little Death - LovesBitca8

  • 21% of women apparently experience this pattern

  • ½ report feeling distressed about it

  • 10% or more have never had an orgasm, 9% rarely have orgasms

  • 50-70% of all women experience orgasm in intercourse at least fairly regularly

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

  • Orgasm during intercourse isn’t mandatory for normal sexual functioning

  • Women who rely on stimulation of the clitoris for orgasm are entirely normal and healthy

  • Biological causes

    • Diabetes can damage the nervous system in ways that interfere with arousal and orgasm

    • Lack of orgasm has sometimes been linked to

      • MS and other neurological diseases

      • Drugs and medications

      • Changes in skin sensitivity and structure of the clitoris, vaginal walls, or the labia

  • Psychological causes

    • Psychological causes of female sexual interest/arousal disorder may lead to female orgasmic disorder

    • Memories of childhood traumas and relationships have sometimes been associated with orgasm problems

  • Sociocultural causes

    • Society’s message to women that they should repress and deny their sexuality

    • Overly strict religious upbringing

    • Punishment for childhood masturbation

    • Sexually restrictive history

    • Unusually stressful events, traumas, or relationships may help produce the fears, memories, and attitudes that often characterize these sexual problems

    • Orgasmic behavior is related to certain qualities in a woman’s intimate relationships

Disorders of Sexual Pain

• Enormous physical discomfort during intercourse

• Women have these dysfunctions much more often than men do

• Genito-pelvic pain/penetration disorder: A sexual dysfunction characterized by significant physical discomfort during intercourse

• Vaginismus / Pelvic floor hypertonus: The muscles around the outer third of the vagina involuntarily contract, preventing entry of the penis

  • Fewer than 1% of all women have vaginismus

  • A number of women with vaginismus enjoy sex greatly, have a strong sex drive, and reach orgasm with stimulation of the clitoris

  • Fear the discomfort of penetration of the vagina

  • Usually a learned fear response

  • May also be caused because of an infection of the vagina or urinary tract, herpes, or the physical effects of menopause

    • In these cases, the dysfunction can be overcome only if the women receive medical treatment for these conditions

• Dyspareunia: Severe vaginal or pelvic pain during sexual intercourse

  • 14-16% of all women suffer from this problem to some degree

  • Typically enjoy sex and get aroused but find their sex lives very limited by the pain that accompanies it

  • Usually has a physical cause

    • Injury during childbirth

    • Scar left by an episiotomy

  • Psychosocial factors alone are rarely responsible for it

• Penetration into an unaroused, nonlubricated vagina is painful

• 1-5% of men suffer from pain in the genitals during intercourse

Treatments for Sexual Dysfunctions

• For the first half of the twentieth century, the leading approach was long-term psychodynamic therapy

  • Expected that broad personality changes would lead to improvement in sexual functioning

  • Typically unsuccessful

What Are the General Features of Sex Therapy?

• Short-term and instructive

• Centers on specific sexual problems rather than on broad personality issues

• Common principles and techniques

  • Assessing and conceptualizing 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 couple interactions

  • Addressing physical and medical factors

What Techniques Are Used to Treat Particular Dysfunctions?

• Disorders of Desire

  • Affectual Awareness: Patients visualize sexual scenes in order to discover any feelings of anxiety, vulnerability, and other negative emotions they may ave concerning sex

  • Self-instruction Training: Help patients change their negative reactions to sex

  • Desire Diary: Patients record sexual thoughts and feelings

  • Hormone treatments

• Erectile Disorder

  • Focus on reducing a man’s performance anxiety, increasing his stimulation, or both

  • Tease Technique: Partner keeps caressing the man, but if the man gets an erection, the partner stops caressing him until he loses it

  • Use manual or oral sex to achieve the woman’s orgasm, reducing pressure on the man to perform

  • Viagra: Drug that increases blood flow to the penis

  • Drugs are the most common form of treatment for erectile disorder

  • Combination of drugs and psychological intervention may be more helpful than either kind of treatment alone

• Premature Ejaculation

  • Pause Procedure: Edging

  • SSRIs

  • Daredevil: Handle with Care - DarkestTimelines

  • We can have some more - orphan_account

• Delayed Ejaculation

  • Techniques to reduce performance anxiety and increase stimulation

  • Man may be instructed to masturbate to orgasm in the presence of his partner

  • Drugs to increase arousal of the sympathetic nervous system

• Female Orgasmic Disorder

  • Cognitive-Behavioral techniques

  • Self-exploration

  • Enhancement of body awareness

  • Directed Masturbation Training: A woman is taught step by step how to masturbate effectively and eventually to reach orgasm during sexual interactions

    • Highly effective

    • Guided Hands - Dreadful Weather Today

  • Hormone Therapy

  • Viagra

• Genito-pelvic pain/penetration disorder

  • Practice tightening and relaxing her vaginal muscles until she gains more voluntary control over them

  • Receive gradual behavioral exposure treatment to help her overcome her fear of penetration

  • Botox in problematic vaginal muscles to help reduce spasms in those muscles

  • Medical interventions

What Are the Current Trends in Sex Therapy?

• Sex therapists regularly treat partners who are living together but not married

• Treat sexual dysfunctions that arise from psychological disorders

• No longer screen out clients

• Pay more attention to excessive sexuality

• Sharp increase in the use of drugs and other medical interventions for sexual dysfunctions

Paraphilic Disorders

• People have repeated and intense sexual urges or fantasies in response to objects or situations that society deems inappropriate, and they may behave inappropriately as well

• Paraphilias: Patterns in which people repeatedly have intense sexual urges or fantasies or display sexual behaviors that involve objects or situations outside the usual sexual norms

• Many people with a paraphilia can become aroused only when a paraphilic stimulus is present, fantasized out, or acted out

• Paraphilic Disorder: A disorder in which a person's paraphilia causes a person significant distress or impairment or when the satisfaction of the paraphilias places the person or other people at risk of harm

• None of the treatments applied to these disorders have received much research or proved clearly effective

• Antiandrogens: Drugs that lower the production of testosterone and reduce the sex drive

  • May reduce paraphilic patterns

  • Disrupt normal sexual feelings and behavior as well

  • Used primarily when the paraphilic disorders are of particular danger

• SSRIs used to reduce compulsion-like sexual behaviors and lower sexual arousal

Fetishistic Disorder

• Recurrent intense sexual urges, sexually arousing fantasies, or behaviors that increase the use of a nonliving object or nongenital body part

• Usually begins in adolescence

• Almost anything can be a fetish

• Some people with this disorder steal in order to collect as many of the desired objects as possible

• Not been able to pinpoint the causes

• Psychodynamic View of Fetishistic Disorder: Fetishes are defense mechanisms that help people avoid the anxiety produced by normal sexual contact

• Psychodynamic treatment has been met with little success

• Cognitive-Behavioral Theory of Fetishistic Disorder: Fetishes are acquired through classical conditioning

  • Aversion Therapy: Electric shock was administered to the arms or legs of participants with this disorder while they imagined their objects of desire

  • Covert Sensitization: People with fetishistic disorder are guided to imagine the pleasurable object and repeatedly to pair this image with an imagined aversive stimulus until the object of sexual pleasure is no longer desired

  • Masturbatory Satiation: The client masturbates to orgasm while fantasizing in detail about fetishistic objects while masturbating again and continues the fetishistic fantasy for an hour

    • Meant to produce a feeling of boredom, which becomes linked to the fetishistic object

Transvestic Disorder

• A person feels recurrent and intense sexual arousal from dressing in clothes of the opposite gender

• Must cause significant distress or impairment to warrant a diagnosis

• Begins cross-dressing in childhood or adolescence

• Often confused with transgender feelings and behaviors

• Cognitive-Behavioral Theory: Transvestic arousal and behavior are learned responses, acquired most often through classical conditioning

Exhibitionistic Disorder

• A person experiences recurrent and intense sexual arousal from exposing his genitals to an unsuspecting individual

• Wants to provoke shock and surprise

• The urge to exhibit typically becomes stronger when the person has free time or is under significant stress

• Begins before age 18

• Usually found among men

• Those with the disorder are typically immature in their dealings with the opposite sex and have difficulty in interpersonal relationships

• Many have doubts or fears about their masculinity

• Treatment generally includes aversion therapy, masturbatory satiation, social skills training, and some form of insight therapy

Voyeuristic Disorder

• Voyeuristic Disorder: A paraphilic disorder in which a person experiences recurrent and intense sexual arousal from observing an unsuspecting individual who is naked, disrobing, or engaging in sexual activity

  • So Baby Whenever You’re Ready - LoadedGunn

  • Whoever, However - Brooklyn_Babylon

• Arousal takes the form of fantasies, urges, or behaviors

• Usually begins before the age of 15 and tends to persist

• May masturbate during or after the act of observing

• Doesn’t generally seek to have sex with the person being spied on

• Vulnerability and humiliation of the person being spied on

• Risk of being discovered

• Psychodynamic Theory: People with voyeuristic disorder are seeking by their actions to gain power over others, possibly because they feel inadequate or are sexually or socially shy

• Cognitive-Behavioral Theory: The disorder is a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene

Frotteuristic Disorder

• A person experiences repeated and intense sexual arousal from touching or rubbing against a nonconsenting person

• Frottage is usually committed in a crowded place

• Usually begins in the teenage years or earlier

• After the age of 15, people gradually decrease and often cease their acts of frottage

Pedophilic Disorder

• A person experiences equal or greater sexual arousal from children than from physically mature people

• Classic Type: Attracted to prepubescent children

• Hebephilic Type: Attracted to early pubescent children

• Pedohebephilic Type: Attracted to prepubescent and early pubescent children

• Usually develop their pattern of sexual need during adolescence

  • Sexually abused as children

  • Neglected or excessively punished

  • Deprived of genuinely close relationships during their childhood

• Often immature

  • Social and sexual skills may be underdeveloped

  • Thoughts of normal sexual relationships fill them with anxiety

• Distorted thinking

  • Blame the children for the sexual contacts

  • Assert that the children benefited from the experience

  • Consider adult sexual activity with children to be acceptable and normal

  • Join pedophile organizations that advocate abolishing the age-of-consent laws

• Most men with pedophilic disorder also display at least one additional psychological disorder

• May be related to biochemical or brain structure abnormalities

• If caught:

  • Imprisoned

  • Forced into treatment

  • Residential registration and community notification

• Treatments

  • Aversion therapy

  • Masturbatory satiation

  • Cognitive-Behavioral Therapy

  • Antiandrogen drugs

  • Relapse-Prevention Training

Sexual Masochism Disorder

• A person is repeatedly and intensely sexually aroused by the act of being humiliated, beaten, bound, or otherwise made to suffer

• Only those who are very distressed or impaired by these fantasies receive a diagnosis

• Act on the masochistic urges by themselves or with sexual partners

  • See me bare my teeth for you - Agf

• Hypoxyphilia: People strangle or smother themselves in order to enhance their sexual pleasure

• Autoerotic Asphyxia: People may accidentally induce a fatal lack of oxygen by hanging, suffocating, or strangling themselves while masturbating

• Most masochistic sexual fantasies begin in childhood, but the person doesn’t act out the urges until early adulthood

• Some people practice more and more dangerous acts over time or during times of particular stress

• Seems to have developed through the learning process of classical conditioning

Sexual Sadism Disorder

• A person is repeatedly and intensely sexually aroused by the physical or psychological suffering of another individual

• May be expressed through fantasies, urges, or behaviors

• Typically imagine that they have total control over a sexual victim who is terrified by the sadistic act

• Many carry out sadistic acts with a consenting partner

  • #ache - shamelessly_mkp

  • practice my maintenance (as hard as you can) - notlucy

  • Professional Distortion - anachronic

• Some act out their urges on nonconsenting victims

  • ex: rapists, sexual murderers

• The real or fantasized victim’s suffering is the key to arousal

• Fantasies may first appear in childhood or adolescence

• Classical conditioning

  • While inflicting pain, a teenager may feel intense emotions and sexual arousal

  • Association sets the stage for a pattern of sexual sadism

• Modeling - Adolescents observe others achieving sexual satisfaction by inflicting pain

• Person inflicts pain in order to achieve a sense of power or control, necessitated by underlying feelings of sexual inadequacy

  • Sense of power increases their sexual arousal

• Signs of possible brain and hormonal abnormalities in people with sexual sadism

• Treated with aversion therapy

  • May not be helpful

• Relapse-Prevention Training may be of value

Gender Variations

• Assigned Gender: The gender a person is born as

• Gender Identity: One’s personal experience of their gender

• Transgender: Individuals who have a sense that their gender identity is different from their assigned gender

• 25 million people in the world are transgender

Transgender Functioning

• Many transgender ppl would like to get rid of their primary and secondary sex characteristics and to acquire characteristics that correspond to their gender identity

• Transgender women outnumber transgender men

• Transgender women: People who identify as female but were assigned male at birth

• Transgender men: People who identify as male but were assigned female at birth

• Sometimes transgender feelings emerge in children

  • Often disappears by adolescence or adulthood

  • In some cases, the individuals do become transgender adults

• Explanations

  • Transgender functioning does sometimes run in families

  • Brains of transgender men have relatively thin subcortical areas, much like those with nontransgender men

  • Brains of transgender women have relatively thin cortical regions in the right hemisphere, much like those of nontransgender women

  • Similarities between transgender individuals and their nontransgender counterparts with regard to the activity and size of brain structures known to play roles in gender functioning and consciousness

  • Brain response similarities between transgender individuals and their nontransgender counterparts have been found in studies that expose participants to certain sounds, visual stimuli, and memory challenges

  • Transgender people don’t have a male or female brain, but rather, a transgender brain

• Options

  • Hormone administration

    • For transgender females:

      • Estrogen

      • Medications designed to suppress their body’s production of testosterone

      • Leads to breast development, loss of body and facial hair, and changes in body fat distribution

    • For transgender males:

      • Testosterone

      • Deeper voice, increased muscle mass, and changes in facial and body hair

  • Speech Therapy

  • Facial Feminization Surgery

  • Gender Reassignment Surgery

    • Usually preceded by 1-2 yrs of hormone administration

    • Transgender women:

      • Face-changing plastic surgery

      • Breast augmentation

      • Genital reconstruction

    • Transgender men:

      • Bilateral mastectomy

      • Chest reconstruction

      • Hysterectomy

      • Genital reconstruction

    • On the rise

    • 70% of patients report satisfaction with the outcome of the surgery

    • Long-term follow-up study found that gender-reassigned participants had a higher rate of psychological disorders and of suicide attempts than the general population

Gender Dysphoria

• Gender Dysphoria: A pattern in which individuals experience significant distress or impairment as a consequence of their transgender feelings

• 90% of transgender persons experience at least a moderate degree of distress or dysfunction at home, school, or work, or in social relationships

• Primary cause for intense dysphoric reactions is the enormous prejudice that transgender persons typically face

  • Harassed, attacked, or murdered in their communities

  • Fired from a job, not hired, not promoted

  • Denied a place to live

  • Stigmatized

  • Excluded from social groups

  • Denied access to appropriate health care

• Emergence and growth of transgender education programs

• Increase in support programs for transgender people

• Mutual help groups available for transgender adolescents and adults

Personal Topics Draw Public Attention

• Education about sexual dysfunctions can be as important as therapy

• Public education about sexual functioning has become a major clinical focus

• Transgender functioning doesn’t represent a mental disorder

• Public education about gender variations is a key to further understanding and process in this realm