Sexual dysfunctions

1. Sexual dysfunctions • 43% women, 31% men in US suffer from sexual problems (age 18-59) • For women, problems decrease with age, except problems of lubrication • For men, problems with desire and erection increase with age • Men 50-59 were 3x as likely to report these as men 18-29 • Pre and post-marital (divorced, separated, widowed) at increased risk for problems • High educational attainment is negatively associated with sex problems for both men and women • Falling household income is assoc with increase in all sexual dysfunctions for women, but only erectile dysfunction for men

2. 4 categories • Sexual desire disorders • Sexual arousal disorders • Orgasmic disorders • Sexual pain disorders • All must be recurrent

3. Sexual desire disorders • Hypoactive Sexual Desire Disorder—little or no interest in sex, absence of fantasies • More common among women • Hard to define low desire, difficult to treat successfully • Often brought in by other member in couple • Causes—bio—testosterone deficiencies, thyroid, diabetes, medication for hypertension, CA, heart, and others • Psych—anxiety, fatigue, lifestyle • Sexual Aversion Disorder—phobia or panic level • May be related to a hx of erectile problems in men; also to rape or sexual abuse

4. Sexual arousal disorders • Previously called impotence and frigidity • Male erectile disorder— • Situational vs. generalized; primary vs. secondary • Performance anxiety—big cause; also depression, s-e, etc. • 10% of men experienced erectile problem in last 12 mos—varies with age • 50-80% are due to organic factors—vascular problems, diabetes, spinal cord injury • Exercise, wt loss, lower cholesterol all improve sexual functioning • Female sexual arousal disorder—both subjective arousal and lubrication • 19% of women have problems with lubrication • Often goes with other sexual disorders like HSDD • Usually situational • More commonly has psych causes—anger and resentment toward partner, sexual trauma, anxiety, guilt, ineffective stimulation • But physical causes also possible—vascular damage, decreased estrogen

5. Orgasmic disorders • Male orgasmic disorder—cannot have orgasm even when highly aroused and had a great deal of stimulation • 8% in last year –not necessarily dx • most often is limited to intercourse • bio causes-MS or neuro condition, side effect of meds, ETOH abuse • also psy causes—hostility, anxiety, guilt • Female orgasmic disorder • 24% of women in last 12 mos • accts for 25-35% of cases of female sex tx • may be related to education, also to spectatoring • Premature ejaculation—hard to define—but too rapid to permit selves or partner to enjoy sex fully. Def varies--<30 sec, <1min, or no voluntary control

6. Sexual pain disorders • Dyspareunia—painful coitus • 14% women, 3% men • In women, most common cause—lack of lubrication • Can also be caused by allergies to spermicides etc., vaginal infections, STDs, PID • Psych causes—guilt, anx, sex trauma • In men—genital infections, smegma • Vaginismus—involuntary contraction of the pelvic muscles that surround outer 1/3 of vaginal barrel. • Intercourse is painful or impossible. • 12-17% of women seeking sex tx. • Not conscious. Not bio based.

7. Biological causes • Always have a physical first! • Fatigue—erectile dysfunction, orgasmic disorders • Poor general health is related to most of these problems. • Alcohol—interplay of expectancy and actual effects • Low levelsexpectancy • High levelsdepressant • Cocaine—can decrease sexual desire, cause erectile or orgasmic dis. • Vascular problems

8. Psychological causes • Cultural influences • cultures that have more negative attitudes toward sex have more dysfunctions • anxiety and shame • women here are taught to be repressive, self-controlled—sexually active but anorgasmic • negative attitudes toward masturbation, sex guilt, greater discomfort talking about sex • Ineffective sexual techniques • Irrational beliefs • Performance anxiety • Sexual trauma • Sexual orientation • Problems in the relationship • Emotional factors

9. Sex therapy • 5 goals • 1) Change self-defeating beliefs and attitudes • 2) Teach sexual skills • 3) Enhance sexual knowledge • 4) Improve sexual communication • 5) Reduce performance anxiety • Therapy usually involves both partners • Bio tx also available—viagra

10. Masters and Johnson • Focus on problem behavior—not cause and how it could be changed • Their original program was 2 week residential • Developed sensate focusing • One partner caresses the other • The other communicates what is pleasurable • No performance demands • Intercourse is initially forbidden • 6 elements (Masters & Johnson, 1970) • Both partners • Male and female sex therapist • Dysfunction is conceptualized as learned—therefore, education • Key causes—performance anxiety, fear of failure, excessive need to please partner • Communication is critical • Treatment is progressive—tasks and behavioral prescription

11. Other approaches • Kaplan’s approach • Not rigid two weeks, but short term • Participation of both is crucial, but not equally • Key—overcoming resistance • PLISSIT Model (Annon, 1976) • Permission-encourage discussion, “normalizes” • Limited information—education, dispelling myths • Specific suggestions • Intensive therapy • LoPiccolo’s Approach • Systems therapy • Integrated (physical and psychological) planning • Sexual behavior patterns

12. Other approaches • Cognitive-behavioral tx—teach script flexibility—novelty is good • Need to make sure that relationship out of bed is a good one • Restructure negative thoughts—all or none thinking • Education is important • Surrogate Partner Therapy • Rare • 60+ hours of training • Specific techniques • Start-stop techniques • Guided masturbation—treats orgasmic disorder in women • Kegel exercises—helpful for women with poor muscle tone after childbirth, increases sexual pleasure by increasing sensitivity of vaginal area

13. Evaluation • Masters and Johnson (1970) reported overall success rate of 80% • After 5 years, 7% relapsed (but only followed up with 29% of sample) • Success varies by dx • Vaginismus 80% • Premature ejaculation 90% • HSDD—most difficult to treat successfully • After program of directed masturbation, 95% of women could have orgasm, 85% with partner, only 40% during coitus • Tx works best when couples are motivated and get along well in other areas • Common factors—Miller, 2001 • No difference by technique • Extratherapeutic (40%)—any and all aspects of client and environment that facilitate changes • Relationship (30%)—rapport with therapist • Placebo/hope/expectancy (15%) • Structure/model/technique (15%)

14. Illness, disability, drugs, and sexuality • About 12% of US is disabled, meaning they have functional deficits in performing ADLs • Myth of asexuality • Illness and self-concept/body image • Believe they are less sexually desirable • Schover, 2000—men are vulnerable to low SE if unable to earn income or perform sexually, may withdraw if they feel ashamed about dependency • But 78% report high of moderately high SE • But on average lower SE than non-disabled

15. Impaired sensory-motor function • Stroke • Associated with decrease in sexual desire, erectile functioning, orgasmic ability, vaginal lubrication, and coital frequency • Why decrease in sex? • Fear of impotence • Inability to discuss sexuality • Unwillingness to participate in sexuality • Spinal cord injury • 82% are men. Most between 16 and 30 • MVA (36%), violence (29%), falls (21%) • Some sexual arousal in most spinal cord patients • Moin et al 2009 • Women with physical disability had the same sexual needs and desires as women without disability • Body image, sexual self-esteem, sexual satisfaction and life satisfaction were significantly lower • Differences were stronger among young adult women than among more mature women • Singh & Sharma, 2005- • Concerns about dysfunction, bladder/bowel dysfunction, bed sores, pain, spasticity, satisfaction of partner • Less likely to marry

16. Multiple sclerosis and cerebral palsy • MS—progressive CNS disease, onset between 20 and 40 • 2-3x more common in women, northern latitude • Sexual dysfunction is common—decreased genital sensation, genital pain, vaginal dryness • Tends to increase in severity over time • CP—brain damage before, at birth, or in infancy • Need counseling and assistance to achieve satisfaction • Wiegerink et al 2008 • Psychological maladjustment, insufficient self-efficacy and low sexual self-esteem may impair the development of social and sexual relationships. • Overprotection in raising children with cerebralpalsy and the negative attitudes of other people may have a negative influence on the self-efficacy of people with cerebralpalsy

17. Diabetes • 6% of population, about 1 million Type 1, 15 million Type 2 • 1/3 unaware of diagnosis • Women • Lack of libido, diminished clitoral sensation, orgasmic dysfunction, vaginal dryness • Men • Progressive softening of penis • Can be permanent damage to ANS

18. Alzheimer’s and other dementias • Alzheimer’s –about 2/3 of all dementia • Often exhibit inappropriate sexual and social behavior • Davies et al, 2010 • Dementia caregivers report difficulties with communication, cohesion, and perceptions of increased burden • Reduced sexual expression due to physical limitations; substitute activities including hand-holding, massaging, and hugging

19. Intellectual disability • Sexual consent capacity • Can say no • Know that intercourse can lead to pregnancy • When given options, can make informed choice • Know sex can lead to a disease • Can distinguish between appropriate and inappropriate times to have intimate relationships • Differentiate between men and women • Can recognize threat • Will stop if another person says no • History of eugenics—23 states between 1907 and 1927 • Families are less open to intimate relationships than are caregivers of ID people (Evans et al, 2009) • Healy et al, 2009 • Young people had only rudimentary knowledge of sexuality issues, for example pregnancy and sexual anatomy, • Aspired to relationships and marriage similar to non-ID • Family and staff attitudes --very influential

20. Mental illness and sexuality • 40% of individuals in US will have mental illness in lifetime • Some mental illnesses and treatments are associated with decreased sexual functioning • Major depression—related to increased erectile dysfunction, decreased sexual desires • Antidepressants—decrease arousal and desire • 30-60% of those taking SSRIs report dysfunction • Schizophrenia • May have symptoms related to sex • Antipsychotic medications can eliminated these sx • But—decrease sexual desire, increase erectile dysfunction and ejaculatory problems • Serious mental illnesses increase risk of victimization • Impaired judgment

21. Medical treatment and sexuality • Some surgery can improve sexual feelings • Endometriosis • Back surgery • Others are negative • Pelvic surgery can damage pelvic autonomic nerves • Hysterectomy • About 1/3 are medically unnecessary • Often performed for benign conditions • About ½--women lose both ovaries • No longer experience uterine contractions—orgasm may change • But in a study of 1000 women, most reported good orgasms, increase sex frequency, and decreased sexual dysfunctions • Medication • Many interfere with sexual functioning • Antidepressants, antihypertensives, drugs that treat heartburn • Chemotherapy—nausea and fatigue

22. Alcohol, other drugs, and sexuality • Substance abuse—1 of… • Failure to fulfill role obligations at work, school, or home • Use in situations in which it is hazardous • Substance-related legal problems • Continued use despite negative effect on relationships • Substance dependence • Tolerance • Withdrawal or avoidance of withdrawal • Failed efforts to quit • Giving up activities due to use

23. Alcohol and substance use • 62% of US adults are current drinkers • 5.7% of men are heavy drinkers (>14 per week) • 3.8% of women (>7 per week) • ¼ of teens and young adults (15-24) report unprotected sex because of drinking or drugs • Expectancy effects • Enhanced sex • Decreased nervousness • Increased riskiness • Greater expectancy effects in heavy drinkers • Long term use • Alcoholism in men leads to decrease in testosterone, less facial hair, breast enlargement, lower libido, erectile dysfunction, • Women—early menopause

24. STDs • Centers for Disease Control, 2007 report • 19 million new STDs in US each year, about 350 million worldwide • Nearly half among those 15-24 • About half of all sexually active young people will contract an STD by 25 • Costs US about $15.9 billion/year • Two most common infectious (bacterial) diseases in the US: gonorrhea and Chlamydia (about 1.5 million total—1.2 Chlamydia, 300,000 gonorrhea) • Undiagnosed/untreated STDs cause about 24,000 cases of infertility each year • Accounts for 15-30% of all infertility • STDs are associated with • Low SES • Drug use (increases risky sexual behavior) • Sexual abuse—about 2x as likely • Lesbians are at decreased risk • Bacterial vs viral infections

25. Consequences of STDs • Health consequences • PID • Transmission to fetus, newborn or infant • Infertility • Economic consequences • National • Treatment—HIV meds may be $1000/month • Psychological consequences • Shock • Withdrawal from social interactions • Anger • Fear • Shame • Depression • In one study of 736 people with AIDS, >40% depressed • Young et al, 2007 • Potential moral stigma leads people to underplay their susceptibility to sexuallytransmitteddiseases • Dampens their interest in getting tested

26. Gonorrhea • Used to be the most widespread STD in the US • African Americans comprise 12% of population but 70% of gonorrhea—one of the largest racial disparities among all diseases • Symptoms • Men • Yellowish, thick, penile discharge, burning urination • Women • Increased vaginal discharge, burning urination, irregular bleeding • Often no early symptoms • Can cause PID • Transmitted almost always through oral, anal, or vaginal sex or during delivery. • Needs warm, moist place to live—dies on toilet seats in a minute • May cause blindness in babies—why babies need silver nitrate • If untreated in men, may cause sterility • Highly contagious—women have 50-90% chance of getting it in just one exposure, men 20-25% • Treated with antibiotics

27. Syphilis • 13,500 cases of syphilis in 2008 • Increasing since 2001 • Due largely to male to male sexual contact • Record low of 5,979 in 2000 • Transmission through sex or through touching a chancre • Pregnant women can give to babies through placenta • Causes miscarriage, stillbirth or congenital syphilis—impaired vision and hearing, deformed teeth and bones • Fetus not harmed if mother is treated before 4th month • 4 stages • Primary • Painless chancre—hard, round, ulcerlike lesion • Secondary • Skin rash--painless red bumps that darken, burst, ooze, h/a, fever aches, flu-like • Latent • Sx go away—dormant for 1 to 40 years • Still multiplying and getting into CNS, circulatory system, bones • Tertiary or late stage • Attacks CNS or cardiovascular system • Can be fatal • Neurosyphilis—brain damage, paralysis, insanity • Can be treated in primary or secondary stages, not after

28. Chlamydia • 92 million new cases worldwide each year • Transmitted vaginally or orally. May also causes eye infection if person touches eye after genitals of an infected person • Also transmitted during birth as child passes through cervix • Each year, about 100,000 babies are infected with bacterium • 75,000 will develop eye infections, 30,000 pneumonia • Can cause blindness—used to account for 15% of all blindness, now less than 4% • Symptoms • Similar to, but more mild than, gonorrhea • Men—nongoncoccal urethritis (NGU) (means not from gonorrhea) • Thin, whitish discharge, soreness in scrotum, pain in urination • Women—cervicitis, urethritis, endometritis, PID • Also—burning during urination, vaginal discharge, pelvic pain, can create infertility, increased chance of ectopic pregnancy • 25-25%men, 70-85% women are asymptomatic • Treated with antibiotics

29. Vaginal infections • Yeast infections • Candidiasis • BCP, antibiotics, diabetes, menstruation, pregnancy can increase risk • Diet high in dairy, sugar, artificial sweeteners • Eating pint of yogurt/day decreases recurrences • Sx in women • Itching, burning, soreness, inflammation, white discharge • Can be passed between partners during oral sex (thrush in mouth) • Also can be passed to men • Sx are itching and burning during urination, reddening of penis—genital thrush • 75% of women will have at least one • Trichomoniasis • Most common curable STD among young, sexually active women • 7.4 million new cases per year • Parasite • Creates foamy whitish to yellow-green discharge, itch/burn • Pain during sex or urination, 5-12% report abdominal pain • Can be passed from men to women, towels, sheets, toilet seats • Most men are symptom free • Treat both partners • Increases susceptibility to HIV in women exposed to HIV

30. HIV • In 1981, when AIDS was 1st found in medical journals, fewer than 100 Americans had died from it • By 2000, nearly 725,000 had AIDs and nearly 500,000 died from it • 850-950,000 currently living with it • 180-280,000 don’t know they’re infected • Leading killer of Americans 25-44 • What are risks? • Unprotected sex • Sharing needles • Blood transfusions (screened here, less elsewhere) • Mother’s milk • Mother to unborn baby • Professional • Not saliva, tears, urine

31. HIV • Factors that affect risk • # of sexual contacts • Type of sexual activity (anal intercourse increases risk) • Amount of virus in fluid • STDs that inflame genital region or create ulcers • Circumcision decreases risk • Genetics • Male to female transmission is 12x greater than female to male • Untreated, 1/3 of babies of infected mothers get HIV. With AZT and c-section, this risk is 3-5% • First symptoms of HIV infection • Mild flu-like • To diagnose AIDS • T-cell count less than 200 • Opportunistic infection • Confidential vs anonymous testing • Window is 30-90 days • 22.4 million people in Africa—2/3 of world’s total of HIV/AIDS • 2008—1.9 million became infected with HIV • 2008—1.4 million died from AIDS • Life expectancy in sub-Saharan Africa is now 47 (used to be 62)

32. Genital herpes • 16% of people 14-49 in US • Two types: HSV I and HSV II • Estimated that 100 million people have oral herpes • Transmitted through oral, vaginal, anal sex. Can survive for hours on objects such as toilet seats. Oral herpes can be transmitted by sharing a cup, kissing, sharing towels • No cure. No vaccine • Blisters may be given a topical to relieve pain, speed healing. Medications to reduce outbreaks • Recurs during stressful times. Transmission more likely during flare-ups. • Can be transmitted elsewhere on body—ocular herpes • Can be transmitted to baby during birth • Coping—herpes syndrome • Feelings of anger, depression, isolation • Feeling tainted, ugly, dangerous, damaged • 75% avoid sex for a long time • May seek infected partners so they don’t have to explain • People perceive herpes as having serious consequences

33. Human Papilloma Virus • Genital warts • More than 40 types • Approximately 20 million Americans are currently infected with HPV. Another 6 million people become newly infected each year. • Each year, about 12,000 women get cervical cancer in the U.S. • May be visible, but in 7/10 not—cervix, urethra • Appear 2-3 months after sex with infected person • Cervical abnormalities in 40-50% of women with HPVincreases risk of cervical cancer • Actually similar to plantar warts—hard and yellow gray when on dry skin, pink, soft cauliflower-like in moist areas • Can also form other places—lips, eyelids, nipples, around anus • Transmitted through skin to skin contact during sex

34. Treatment and vaccines • Treat –freeze off with liquid nitrogen or paint with alcohol-based solution, but virus remains • Vaccines can protect males and females against some of the most common types of HPV. • These vaccines are given in three shots. It is important to get all three doses to get the best protection. • The vaccines are most effective when given before a person's first sexual contact, when he or she could be exposed to HPV

35. Pubic lice • Related to head lice • Large enough to be seen with eye—1.1 to 1.8 mm • Spread sexually, by infected towel • Not likely to be spread by toilet seat • Can only survive 24 hrs without human host, but can lay eggs that last 7 days • Itchy • By the way—animals do not get or spread this

36. Prevention of STDs • Know the risks • Abstain • Stay sober • Inspect yourself and your partner • Use latex condoms • Wash genitals before and after sex • Avoid high-risk sexual behavior • Get regular medical check ups • Know your partner—encourage testing • Avoid other high risk behaviors—sharing needles, towels, cuticle scissors, razors

37. Normal vs. deviant sexual behavior • Statistical infrequency • Deviation from social norm (moral correctness) • Naturalness • Adaptiveness/comfort

38. Paraphilias • Recurrent, intense sexually arousing fantasies that generally involve nonhuman objects, suffering or humiliating oneself or one’s partner, or nonconsenting people • Usually feel urges are insistent, compulsive quality. • Nearly all male. • Vary in severity • Usually occur in clusters—over half show more than one • To dx, must be present for 6 months. There are 8 paraphilias, 5 of which we can dx if people act on them, regardless of whether or not the person experiences distress

39. Fetishes • Sexual fixation on some object other than another human and attachment of erotic importance to that object • Media—type of material • Form—particular shape • Related—partialism—excessively aroused by a particular body part • Not typically harmful • Generally private, consent of partner • Typically occurs before puberty

40. Transvestic fetishism • Up to 6% of men by some estimates • Cross dressing does not equal transvestism—some men dress in drag for other reasons • For the transvestite—sexually arousing • Not typically harmful—typically in private or with consent of partner • Generally have a strong male identity (68% hetero) • Origin unknown • May be related to family somehow • Most keep transvestism secret, even from partners or wives • When wives find out, most are confused or shocked • Most try to be understanding at first • Later become more negative • Reasons as adults—sexually arousing, relaxing, role playing, adornment

41. Exhibitionism • Sexual arousal from exposing genitals to others in culturally inappropriate situations • Cross-culturally, fewer than 20% are reported to police • 1/3 of college women have been victims of this • 30% of all arrests for sexual offenses are for flashing • About 10% of rapists and child molesters (in one sample) began as flashers • Urge to exhibit begins in early adolescence., exhibitionism itself usually begins before age 18. Frequency declines after 40 • What they are like: • Typically young, unhappily married, timid, unassertive, lacking in social skills, lacking in sexual skills, doubts about own masculinity, suffer from feelings of inadequacy, many report overprotective mothers and poor rel. with fathers • Preferred victims are girls or young women • Indirect means of expressing hostility toward women, but they aren’t in touch with this • About 50% report erections during, usually masturbate later

42. Telephone scatalogia • Few are women—women who do this are typically motivated by rage/revenge • Males—motivated by desire for sexual excitement • Most aren’t dangerous, don’t make repeated calls to the same person • Many patterns—obscenities, breathe heavily, sexual overtures, sex surveys, etc. • Like exhibitionist-socially inadequate heterosexual male who can’t form intimate relationships

43. Voyeurism • Become sexually aroused from secretly viewing nudes • Usually begins by age 15. Almost exclusively found in males • Unsuspecting is key—not pornos or strippers • Most are nonviolent, but may be violent if provoked • More dangerous—1) those who break in 2) those who draw attention to themselves • Risk is an element of the arousal • Tend to be less sexually experienced, not likely to be married, harbor feelings of inadequacy, lack social skills, less likely to have sisters or female friends

44. Sadism and masochism • Masochism is the only paraphilia found with any frequency in women—about 5% of masochists are women • Sadomasochism is highly ritualized—not all pain is gratifying • In a mild form—not uncommon • Kinsey found 26% men and women found being bitten erotic as part of sex act • 22% men, 12% men reported arousal to S&M stories • Pain may be symbolic • Serious injury is usually avoided • Survey from S&M magazine—3/4 male, most married, men interested since childhood, women introduced to it • Causes—may have bio links to pleasure—pain causes release of endorphins, but this doesn’t explain symbolic pain or sadism • Learning theorists—being spanked for masturbation • Sociologists—losing control, letting go

45. Frotteurism • Rubbing or touching a nonconsenting person • Buses, subways, elevators • May imagine a consensual relationship—in reality, are very afraid of rejection • Japan • Street groping is called chikan and the man who commits such acts is also called chikan • Crowded trains are a favorite location for groping, and a 2001 survey conducted in two Tokyo high-schools revealed that more than 70% of students had been groped while travelling on them • Some railway companies designate women-only passenger cars during rush hours • Chikan is often featured in Japanese pornography

46. Other paraphilias • Zoophilia • Necrophilia • Klismaphilia—enemas • Coprophilia—feces • Urophilia--urine

47. Origin of paraphilias • Psychoanalytic theory • Unconscious conflicts • Domineering mother • Unresolved Oedipal conflict • Feminist perspective • Pedophilia, sadism—aggression • Traditional gender roles emphasize male dominance, sexual aggression, control, hostility • Learning theory • Classical and operant • Biological theory • Paraphilias correlate with other mood disorders like depression, anxiety, and bipolar • Paraphilias as vandalized lovemap • John Money • Mental template that develops early in life

48. Prevention • 3 components of sexual development • Gender identity • Sexual responsiveness • Formation of relationships with others • Different components in each diagnosis

49. Treatment • Problems— • 1) Don’t want/seek tx • 2) No motivation to change even if in tx (thus cog tx doesn’t work) • 3) Should therapist impose own goals? • 4) Perceived responsibility—client must know he can change • Behavior tx • Systematic desensitization—pair relaxation with arousing images • Aversion tx—shock, nausea inducing drugs • Social skills training • Orgasmic reconditioning—begin with old images, then switch to appropriate ones • Drugs • Prozac—some effectiveness for exhibitionism, voyeurism, fetishism (OCD-type beh) • Anti-androgen drugs—depo provera—decreases sexual desire in those at risk for sexual offenses. Decreases desire—not urges or behavior in a particular direction. High refusal and drop out rates for this treatment.

50. Exploitative dating relationships • Types of abuse • Emotional/mental/verbal • Environmental • Social • Financial • Religious • Sexual • Physical