Sexual Disorders and Dysfunctions

Prevalence and Assessment of Sexual Disorders

Sexual disorders are common, with studies indicating:
- Approximately 31% of men in the US experience sexual dysfunction.
- Approximately 43% of women in the US experience sexual dysfunction.
Prevalence rates vary across studies due to assessment differences, which is a major issue in diagnosing sexual disorders.

Defining Sexual Problems as Disorders

Many people experience sexual problems, but not all warrant a diagnosis of a sexual disorder.
The key criterion for a sexual disorder diagnosis is that the disturbance causes clinically significant distress.

Three Common Criteria for Sexual Disorders

All sexual disorders must have the following three aspects:
- Clinically Significant Distress:
  - The individual must be upset about the sexual problem.
  - Distress varies significantly among individuals regarding their sex lives.
  - Example: A couple in marital therapy who had sex infrequently (twice in 18 months) did not have a sexual dysfunction diagnosis because neither partner was distressed by it.
- Not Better Explained by Other Factors:
  - The sexual dysfunction should not be better explained by a non-sexual mental disorder, severe relationship distress, stressors, substance/medication effects, or another medical condition.
  - It's crucial to determine if the sexual dysfunction is the primary issue or an effect of something else.
  - Examples:
    - Clinical depression can decrease the desire to engage in sexual activity.
    - Relationship problems or anger can reduce sexual desire.
    - Significant stressors like job loss or family illness can affect sexual performance.
    - Certain drugs (including substances of abuse or prescribed medications) can negatively impact sexual performance.
      - SSRIs (selective serotonin reuptake inhibitors) like Paxil, Prozac, or Zoloft can increase the time to orgasm or prevent it completely.
    - Underlying medical conditions or pain can affect an individual's sex life.
- Minimum Duration of Symptoms:
  - Symptoms must persist for a minimum duration of approximately six months.
  - This criterion ensures the problem is not just a temporary blip or phase.

Subtypes of Sexual Disorders

After diagnosing a sexual dysfunction, clinicians determine three subtypes:
- Lifelong vs. Acquired:
  - Lifelong: The disturbance has been present since the individual became sexually active.
  - Acquired: The disturbance began after a period of relatively normal sexual function.
- Generalized vs. Situational:
  - Generalized: The dysfunction is not limited to certain types of stimulation, situations, or partners.
  - Situational: The dysfunction only occurs with certain types of stimulation, situations, or partners.
    - Examples:
      - A man experiences erectile dysfunction with his wife but not with a girlfriend.
      - A woman achieves orgasm through masturbation but not during sexual intercourse.
      - Difficulty performing satisfactorily in particular places.
- Mild, Moderate, or Severe:
  - The clinician determines the severity of the disorder.
    - For some disorders (e.g., premature ejaculation), the DSM provides specific criteria.
      - Mild: Ejaculation occurs within approximately 30 seconds to 1 minute of vaginal penetration.
      - Moderate: Ejaculation occurs within approximately 15 to 30 seconds of vaginal penetration.
      - Severe: Ejaculation occurs prior to sexual activity or within approximately 15 seconds of vaginal penetration.
    - For others (e.g., female sexual interest arousal disorder), the DSM relies on the level of distress.
      - Mild: Evidence of mild distress over the symptoms.
      - Moderate: Evidence of moderate distress over the symptoms.
      - Severe: Evidence of severe or extreme distress over the symptoms.

Criticisms of the DSM-5 Sexual Dysfunctions Chapter

Ambiguity in diagnostic criteria remains a concern, making reliable and valid diagnoses difficult.
Comorbidity is high, meaning individuals often meet diagnostic criteria for more than one disorder.
- Example: A woman with genito-pelvic pain penetration disorder may also experience female sexual interest arousal disorder due to anxiety about pain.

Other Specified and Unspecified Sexual Dysfunction

Substance/Medication-Induced Clinically Significant Disturbance in Sexual Function:
- The clinically significant disturbance in sexual function developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
- This diagnosis does not require the six-month duration criterion.
When an individual is experiencing a sexual dysfunction, is distressed about this, but the problem doesn't meet the criteria for one of the sexual dysfunctions already talked about, use other or unspecified sexual dysfunction.
- These diagnoses do require the common criteria of 6 months of distress, and require that the dysfunction be due to another issue.
Other Specified Sexual Dysfunction:
- Used when an individual has symptoms characteristic of a sexual dysfunction that causes clinically significant distress but does not meet full criteria for any other disorder.
- The clinician communicates the specific reason the presentation does not meet the criteria (e.g., sexual aversion).
Unspecified Sexual Dysfunction:
- Used when an individual presents with symptoms characteristic of a sexual dysfunction that cause clinically significant distress but does not meet full criteria for any other disorder.
- The clinician chooses not to specify the reason the criteria are not met, often due to insufficient information.

Broad Categories of Sexual Dysfunctions

Sexual dysfunctions can be categorized into four broad categories based on Masters and Johnson's and Kaplan's models of the human sexual response cycle:
- Sexual Desire Disorders
- Sexual Arousal/Excitement Disorders
- Orgasmic Disorders
- Pain Disorders

Specific Sexual Disorders

Male Hypoactive Sexual Desire Disorder:
- Men report deficient or absent sexual fantasies and desire for sexual activity.
- Deficiency is determined by the clinician, considering age, general and sociocultural contexts.
- It must cause clinically significant distress and persist for at least six months.
Female Sexual Interest Arousal Disorder:
- Bridges desire and excitement categories.
- Requires three or more of the following six symptoms:
  - Absent or reduced interest in sexual activity.
  - Absent or reduced sexually erotic thoughts and fantasies.
  - No or reduced initiation of sexual activity and typically un receptive to a partner's attempts to initiate sexual activity.
  - Absent or reduced sexual excitement or pleasure during sexual activity (75-100% of the time).
  - Absent or reduced sexual interest or arousal in response to any internal or external sexual or erotic cues.
  - Absent or reduced genital or non-genital sensations during sexual activity (75-100% of sexual encounters).
- Having just 3 criteria can make the diagnosis different across different women.
Male Erectile Disorder:
- Difficulty in obtaining or maintaining an erection.
- One of the following criteria must be experienced 75-100% of occasions of 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 erectile rigidity.
Female Orgasmic Disorder:
- One of the following must be experienced during 75-100% of occasions of sexual activity.
  - Marked delay in, marked infrequency of, or absence of orgasm.
  - Markedly reduced intensity of orgasmic sensations.
- It is difficult to diagnose, especially with marked delay in orgasm, because we don't know averages for time reaching orgasm.
- Must determine if sexual stimulation actually is adequate (e.g. clitoral stimulation is necessary for women).
Premature (Early) Ejaculation:
- A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately one minute following vaginal penetration and before the individual wishes it.
- Although, traditionally premature ejaculation can be diagnosed in gay men and doesn't require vaginal penetration.
- The issue must occur 75-100% of the time that men engage in sexual activity.
Delayed Ejaculation:
- During 75-100% occasions of sexual activity, men experience marked delay in ejaculation.
- The average from that starting sex to ejaculation is unknown, making this hard to diagnose.
Genito-Pelvic Pain Penetration Disorder:
- This is the sole pain disorder diagnosed solely in women where used to be dyspareunia (which could be diagnosed in men and women) and vaginismus.
- Persistent or recurrent difficulties with one or more of the following:
  - Vaginal penetration during intercourse
  - Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
  - Marked fear or anxiety about pain in anticipation of, during, or as a result of vaginal penetration.
  - Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

Goals of Sex Therapy

When an individual or couple comes to see a therapist for issues relating to sexual dysfunction it isn't uncommon and can be quite difficult for that person or couple to make.
Also, it is remarkable how little people actually know about sex and what they find sexually satisfying.
One or the primary goals of sex therapy is to educate.
Men have a much better understanding about their genitals and women don't know what their genitals look like and how they function, so a homework assignment given is to look at the genitals in the mirror and identify all the different structures.
It is important to see a medical doctor because there are biological factors that can be contributing to sexual dysfunction.
Overal Goals:
- Change negative beliefs and attitudes.
  - Sexual satisfaction is a noble goal provided that nobody gets hurt and what you're doing is healthy.
- Increasing sexual knowledge.
  - Educating about how bodies work (both client and partners).
- Teach specific sexual skills.
  - Techniques to solve different disorders.
- Improving communication between partners.
  - It's difficult to discuss sex, pleasure, and experiences, so try to have better communication in therapy and by being aware.
- Reduce performance anxiety.
  - Spectatoring is hovering above the bed and disrupts the ability to perform effectively. Example: worrying about satisfying partner in heterosexual couple or not being attractive.

PLISSIT Model of Sex Therapy

There is absolutely no sexual activity that takes place in office.
Created in 1976 it is a 4 stage hierarchical model.
- Permission. Therapist reassure clients that the thoughts, feelings, desires and behaviors that enhance their satisfaction and do not have potentially negative consequences are normal.
- Information. Therapists provide clients with information specific to their sexual concerns. A reminder that it is good to be a teacher, and look things up if needed.
- Specific Suggestions. Therapists assign homework assignments that treat sexual dysfunction. For example, masturbation training or the stop start technique.
- Intensive Therapy.
  - There are emotional difficulties or relationship problems that may interfere with sexual expression. In this case intensive individual or couples therapy that is necessary.
  - Important to refer out individuals to stop secrets, so couples can have honesty with each other.

Homework Assignments in Sex Therapy

Sensate Focus:
- A general assignment that a sex therapist will ask a couple to engage in. Most couples focus too much on orgasm rather than the sensuality.
- Moratorium on sexual intercourse, the client comes in with a disbelief.
- 4 stages
  - Non-Genital Pleasuring: Not woriking on pleasuring your partner, but heightening your senses.
    - At least twice a week set aside 20 minutes, with no stress or pressure.
    - Instruct the couple not to talk, unless touch is uncomfortable or painful on unrelated masters.
  - Genital Pleasuring.
    - Once again, caressing the entire body, and maybe running hands along back, arms, and legs, there is no longer genital off limits.
  - Genital Containment.
    - Start having non genital pleasuring in the session and then move onto genital pleasuring and then when that feels right, then penis inserted into the women's vagina.
    - No Thrusting allowed, seems difficult but if clients do that then that can happen.
  - Thrusting and Intercourse
    - Allows thrusting and intercourse. However therapist makes sure to underscore no that orgasm isnt the marker for success instead intimacy is there.

Specific Techniques that are very effective to treat some sexual dysfunctions.

*   **Female Orgasmic disorder:**
    *   These are individuals who are unable to reach orgasm.
        *   Goal is what feels pleasurable and what stimulation is needed to achieve orgasm.
        *   Masturbation training is common where therapist tells the woman to explore that and have clitoral stimulation and find pleasure by being alone.
    *   Kegel Exercies.
        *   Where one finds that they can release that muscle/squeeze that controls urine for the urination.
    *   Coital Alignment.
        *   With partner ensure the penile thrusting when getting maximal clitoral stimulation.
*   **Genitopelvic pain penetration disorder** (Vaginismus)

    *   A woman's vaginal muscles or pelvic floor muscles are contract so that penetration is impossible.
    *   Teach the woman relax muscles to vagina.
    *   Dilators is helpful to gradually put into the vagina, but must all take place at home and its discussion with specific techniques that comes out.
*   **Premature Ejaculation**
    *   Goal here is to recognize point and ejaculatory inevitability.
        *   Squeeze Technique.
            *   One masturbates places thumb and pointer finger and middle finger go over the top of the peninsula and squeeze once getting close to ejaculatory inevitability.
        *   Basilar Squeeze Technique.
            *   Same idea, man is masturbating and then at base is squeezed by three fingers.
        *   Stop Start Method.
            *   Important to inform them to do this with vaginal on top. And can nonverbally communicate for thrusting to stop.
*   Drugs. Many of the prescriptions are due to side effects. It is more psychological though, drugs do contribute something.