Psych 360 Chapter 12

-        Sexual norms and behavior

o   What is normal or desirable vary with time and place

§  19^th and early 20^th centuries

·        Excess sexual expression was problematic

§  Contemporary Western worldviews

·        Inhibition of sexual expression is seen as a problem

o   Sexual revolution of 1970s

§  Availability of birth control led to shifts in attitudes toward premarital sex

-        Research methods in the study of sexuality

o   Research focused on normative sexual behavior has gone through a series of revolutions

§  1940s research focused on interviewing people about their sexuality

§  1950s use of direct observations and physiological assessments during masturbation or sexual intercourse

o   Physiological responses to sexual stimuli can be assessed using penile or vaginal plethysmographs

o   Stigma may interfere with sexuality research

-        Gender and sexuality     

o   Men are more likely to

§  Meet the diagnostic criteria for paraphilic disorder

§  Endorse engaging in masturbation and using pornography

o   Women are more likely to report sexual dysfunction

o   Gender differences in sexuality have decreased over time

o   Reported gender differences in sexual behavior may reflect respondents’ attempts to match cultural expectations

o   Older research in male samples concluded that sexual interest preceded subjective arousal and would be followed by biological arousal

o   However, later research that included women found that sexual interest and subjective arousal often co-occur so sexual interest would often follow biological arousal for women

-        DSM-5 disorders involving sexual interest, desire, and arousal

o   Female sexual interest/arousal disorder

§  Persistent deficits in sexual interest (fantasies or urges), biological arousal, or subjective arousal

§  Diminished, absent, or reduced frequency of at least three of the following:

·        Interest in sexual activity

·        Erotic thoughts or fantasies

·        Initiation of sexual activity and responsiveness to partner’s attempts to initiate

·        Sexual excitement/pleasure during 75% of sexual encounters

·        Sexual interest/arousal elicited by any internal or external erotic cues

·        Genital or nongenital sensations during 75% of sexual encounters

o   Male hypoactive sexual desire disorder

§  Deficient or absent of sexual fantasies and urges

§  Sexual fantasies and desires, as judged by the clinician, are deficient or absent

o   Male erectile disorder

§  Failure to attain or maintain an erection

§  On at least 75% of sexual occasions, one of the following occurs

·        Inability to maintain an erection

·        Inability to maintain an erection for completion of sexual activity

·        Marked decrease in erectile rigidity interferes with penetration or pleasure

o   In general, diagnoses are not made when better explained by:

§  Identifying as asexual

§  Nonsexual mental disorder

§  Relationship distress or other stressors

§  Medication/substance, medical condition

-        DSM-5: Orgasmic Disorders

o   Female orgasmic disorder

§  Persistent absence or reduced intensity of orgasm after sexual arousal

§  On at least 75% of sexual occasions

·        Marked delay, infrequency, or absence of orgasm

·        Markedly reduced intensity of orgasmic sensation

o   Early ejaculation disorder

§  Ejaculation that occurs too quickly

§  Tendency to ejaculate during partnered sexual activity within 1 minute of penile insertion on at least 75% of sexual occasions

o   Delayed ejaculation disorder

§  Persistent difficulty in ejaculating

§  Least common, reported by less than 1% of men

§  Marked delay, infrequency, or absence of orgasm on at least 75% of sexual occasions

-        Sexual pain disorders

o   Genito-pelvic pain/penetration disorder

§  Persistent or recurrent pain during intercourse

§  Must rule out medical cause (e.g., infection), lack of vaginal lubrication, or postmenopausal changes

§  Many can experience sexual arousal and orgasms from manual or oral stimulation that does not involve penetration

§  DSM-5 criteria

·        Persistent or recurrent difficulties with at least one of the following

o   Marked vulvar, vaginal, or pelvic pain during vaginal penetration or intercourse attempts

o   Inability to have vaginal penetration during intercourse

o   Marked fear or anxiety about pain or penetration

o   Marked tensing of the pelvic floor muscles during attempted vaginal penetration

-        Etiology of sexual dysfunctions

o   Biological influences

§  DSM-5 includes separate diagnoses for sexual dysfunctions caused by medical illnesses

·        Somewhat controversial because many sexual dysfunctions have a biological contribution

§  Biological influences include

·        Diabetes, multiple sclerosis, spinal cord injury, heavy alcohol use before sex, chronic alcohol use, heavy cigarette smoking

§  Autonomic nervous system

·        Excessive activation of SNS (inhibits blood flow to genitals)

·        Deactivation of PNS

§  Hormone levels

·        Low levels of testosterone or high levels of anabolic steroids or testosterone supplements

§  Side effect of some medications

·        SSRIs can blunt sexual activity—serotonin increases inhibition of sexual responses

§  Biological influences particularly important for erectile dysfunction and premature ejaculation

o   Social and psychological influences

§  History of rape, sexual abuse, absence of positive sexual experiences

§  Social and cultural learning

§  Relationship problems

·        E.g., anxiety, anger, embarrassment, poor communication

§  Stress and exhaustion

§  Depression and anxiety

§  Negative cognitions

·        Self-blame

-        Treatments of sexual dysfunctions

o   Psychoeducation

§  Normalize symptoms, reduce anxiety, model effective communication, eliminate blame

o   Couples therapy

§  Training in nonsexual communication skills

§  Focus on nonsexual issues

§  Focus on communication and restoration of intimacy

o   Cognitive interventions

§  Challenge self-demanding, perfectionistic thoughts

o   Sensate focus

§  Re-establish intimacy by engaging in contact through touch

o   Limited success in identifying medical treatments for sexual dysfunction disorders among women

-        Treatments for specific female sexual dysfunctions

o   Female sexual interest/arousal disorder

§  FDA recently approved the medication Addyi for premenopausal women with low sexual desire

§  Efficacy is limited with significant side effects

o   Female orgasmic disorder

§  Directed masturbation

§  60-90% of that subgroup achieving orgasm post-treatment

o   Genito-pelvic pain/penetration disorder

§  Trained in relaxation

§  Practice inserting smaller and then larger dilators into vagina

-        Treatments for specific male sexual dysfunctions

o   Premature ejaculation

§  SSRI taken 1 hour before sex

§  Squeeze technique

·        Partner is trained to squeeze the penis in the area where the head and shaft meet to rapidly reduce arousal

§  Withdraw penis as needed during intercourse to reduce arousal

§  Psychotherapy to regain confidence after experiences of these symptoms

o   Erectile disorder

§  Medication (e.g., Viagra)

§  83% able to successfully have intercourse

-        The paraphilic disorders

o   Recurrent sexual attraction to unusual objects or sexual activities

o   Lasting at least 6 months

o   Should only be diagnosed when

§  There is marked distress or impairment

§  Behaviors are done with nonconsenting persons

o   Divided categories based on source of arousal

§  Sexual attractions based on inanimate objects

§  Sexual attractions based on children

o   Accurate prevalence statistics are not available

o   Fantasizing or engaging in many of these behaviors may be relatively common and not necessarily part of a clinical disorder

o   Fetishistic disorder

§  Reliance on an inanimate object or nongenital part of the body for sexual arousal

§  recurrent and intense sexual urges toward these fetishes

·        presence of the fetish is strongly preferred or even necessary for sexual arousal

§  compulsive attraction to the object

·        the attraction is experienced as involuntary and irresistible

§  DSM-5 criteria

·        For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviors involving the use of nonliving objects or nongenital body parts

·        Causes significant distress or impairment in functioning

·        The sexually arousing objects are not limited to articles of clothing used in dressing as another gender, nor to devices designed to provide tactile stimulation, such as a vibrator

o   Pedophilic disorder

§  Diagnosed only when adults act on their sexual urges toward children, or when the urges cause distress to the person or those close to them

§  Victims are usually known to the pedophile

·        Most pedophilia does not involve violence other than the sexual act

§  Pedophiles show more arousal to sexual stimuli involving children than to stimuli involving adults

§  Incest subtype

·        Sexual relations between close relatives for whom marriage is forbidden

§  DSM-5 criteria

·        For at least 6 months, recurrent and intense, sexually arousing fantasies, urges, or behaviors involving sexual contact with a prepubescent child

·        Person has acted on these urges and fantasies cause marked distress or interpersonal problems

·        Person is at least 16 years old and 5 years older than the child

o   Voyeuristic disorder

§  Intense and recurrent desire to obtain sexual gratification by watching

·        Unsuspecting others in a state of undress

·        Having sexual relations

§  Common in men

§  May not find it particularly exciting to watch someone undress for his benefit

·        The element of risk, and the threat of discovery, is important

§  DSM-5 criteria

·        For at least 6 months, recurrent, intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors

·        Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause clinically significant distress or interpersonal problems

o   Exhibitionistic disorder

§  Exposing one’s genitals to an unwilling stranger

·        Seldom an attempt to have other contact with the stranger

·        Usually involves desire to shock or embarrass the observer

§  Many exhibitionists masturbate during the exposure

§  DSM-5 criteria

·        For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviors involving showing one’s genitals to an unsuspecting person

·        Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause clinically significant distress or interpersonal problems

o   Frotteuristic disorder

§  Sexually oriented touching of an unsuspecting person

·        Rubbing genitals against a person’s body or fondling a person’s genitals

·        Often occurs in crowded places

§  DSM-5 criteria

·        For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviors involving touching or rubbing against a nonconsenting person

·        Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause clinically significant distress or problems

o   Sexual sadism and masochism disorders

§  Sexual sadism disorder

·        Inflicting pain or psychological suffering (such as humiliation) on another

§  Sexual masochism disorder

·        Being subjected to pain or humiliation

§  Most sadists establish relationships with masochists to derive mutual sexual gratification

§  Debate over inclusion in DSM-5

·        These disorders have become more common

·        Typically do not cause impairment or distress

·        Rarely a focus of treatment

§  DSM-5 criteria

·        Sexual sadism

o   For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviors involving the physical or psychological suffering of another person

o   Causes clinically significant distress or impairment in functioning or the person has acted on these urges with a nonconsenting person

·        Sexual masochism

o   For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviors involving the act of being humiliated, beaten, bound, or made to suffer

o   Causes marked distress or impairment in functioning

o   Etiology of paraphilic disorders

§  Neurobiological influences

·        Almost all individuals with paraphilias are men

·        They do not have unusual levels of testosterone or other androgens

§  Psychosocial influences

·        History of childhood sexual abuse: 40-66% of adult sexual offenders reported a history of sexual abuse

·        Loss of control over behavior

·        Heightened impulsivity and poor emotion regulation

·        Poor recognition of emotional expression of others

·        Slightly lower IQ and higher rates of neurocognitive problems

·        More minor physical anomalies related to prenatal development

o   Treatment for the paraphilic disorders

§  Very little is known about the effectiveness of treatments

·        Research often focuses on men charged with sexual offense

·        Very little long-term data is available

·        Unethical to withhold treatment

o   Lack of control groups (RCTs)

§  Treatments aim to enhance motivation for treatment

·        Bolster hope for control over urges

·        Focus on benefits for change and consequences of continued engagement in illegal sexual behaviors

§  Cognitive behavioral

·        Aversion therapy

o   Pair paraphilic fantasies with aversive stimuli

·        Covert sensitization

o   Asked to imagine negative consequences of inappropriate sexual behavior

·        Modify distorted thinking

·        Often combined with social skills, sexual impulse control strategies, empathy training, and relapse prevention

§  Biological

·        Medications (supplement to psychological treatment)

o   Hormonal agents to reduce androgens

§  Limited RCT data available and difficult to interpret due to drop out rates

§  Lack of evidence of elevated androgens in paraphilic disorders, which suggests androgens may not be a good treatment target

o   SSRIs

§  Used despite lack of empirical support

o   Prevention

§  Often treatment only takes place after an individual is charged with a crime

§  In 2004, major efforts began to try to identify and intervene with men who experience sexual attractions to children through community outreach across several countries

§  Cognitive behavioral therapy and medication approaches

§  Some evidence of effectiveness of these approaches

o   Balancing public protection vs. civil liberties of offenders

§  Balance between protecting the public and protecting the civil liberties of sexual offenders

·        E.g., laws concerning the public’s “right to know” when a sex offender is released

§  Unconstitutional to detain a person based on potential for future crimes. However:

·        Supreme court ruled that a person at high risk for a sex crime can be detained if the risk is related to a psychological disorder diminishing the person’s ability to control sexual behavior

§  Receipt of a paraphilic diagnosis can lead to placement in a psychiatric facility after a prison term is completed