Human Sexuality

1. Human Sexuality Sexual Disorders: Dysfunction, Dysphoria, and Paraphilia

2. Sexual Myths and Realities • Pre-1966/ Masters & Johnson’s “Human Sexual Response”; The Science of Sexuality • Accepted beliefs about Human Sexuality: • Masturbation is rare and causes disease in men • Women never masturbate • Homosexuality is abnormal • Most couples have exclusively missionary sex • Women are not sexual and rarely have orgasms • Premarital sex is rare; so is extramarital sex

3. What is “Normal” Sexual Behavior? • Normal Sexual Behavior: Wide range; research is recent and evolving • Difficult to determine what is normal • Example: people report tremendous variation in frequency of sexual outlet or release • Influenced by cultural norms and values • Kinsey: “The only unnatural sex act is that which you cannot perform” • Definitions of sexual disorders are inexact

4. Defining Sexual Behavior as a Mental Disorder • Controversy surrounding definition of deviant sexual behavior • Current Def: Only deviant if it threatens society, causes distress to participants, or impairs social or occupational functioning • Is gender dysphoria a psychiatric disorder? • Is Sex Addiction a disorder? • Is hyposexuality a disorder if there is no distress?

5. The Sexual Response Cycle • Appetitive/Excitement phase • Characterized by person’s interest in sexual activity • Arousal/Plateau phase • May follow or precede the appetitive phase • Heightened when specific, direct sexual stimulation occurs • Various physical changes occur • Example: increased blood flow to penis in males

6. The Sexual Response Cycle (cont’d.) • Orgasm phase • Characterized by involuntary muscular contractions throughout the body and eventual release of sexual tension • Resolution phase • Characterized by relaxation of the body after orgasm • Heart rate, blood pressure, and respiration return to normal

7. Human Sexual Response Cycle

8. Sexual Dysfunctions • Recurrent and persistent disruption of any part of the normal sexual response cycle • DSM-5 requires that symptoms be present for at least six months and be accompanied by significant distress • Types of dysfunctions • Lifelong – onset since beginning of sexual behavior • Acquired – after a period of normal sexual behavior • Generalized – across situations, partners, all stimulation • Situational – specific to certain situations, partners, stim

9. Sexual Dysfunction Dx • DSM-5 diagnosis for sexual dysfunction not made if better explained by another disorder (i.e., depr) • Sexual Dysfunction can be comorbid with relational difficulties and psychological disorders Example: Loss of Sexual Arousal Drive subsequent to relationship conflict; poor body image; grief

10. Lifetime Prevalence of Sexual Disorders in the United States (40–80 Age Range)

11. Sexual Interest/Arousal Disorders • Problems with initial phase of sex: little interest in sex but capable of orgasm • What is normal frequency? 2-3x wk? year? • Male hypoactive sexual desire disorder • Little or no interest in sexual activities • Female sexual interest/arousal disorder • Little or no interest, or diminished arousal to sexual cues • Most common in women – 33% • 40-50% of all sexual difficulties involve deficits in interest

12. Orgasmic Disorders • Female orgasmic disorder (prevalence 10-40%) • Persistent delay or inability to achieve orgasm despite receiving adequate sexual stimulation • Marked reduced intensity of orgasmic sensation • Not dx if orgasm is possible with stimulation • Delayed ejaculation – (worsens with age) • Persistent delay or absence of ejaculation after excitement phase is reached • Lifelong type can occur • Rule out Medical Cause: surgical injury to lumbar nerves; nerve supply to genitals

13. Orgasmic Disorders • Premature Ejaculation • Recurrent pattern of having an orgasm with minimal sexual stimulation before, during, or after vaginal penetration • Must occur within one minute of penetration • Most common sexual dysfunction for young men • Affects 21-33 percent of men

14. Orgasmic Disorders • Pain Penetration Disorders: Involves physical pain or discomfort associated with intercourse/penetration • Dyspareunia • Pain in the pelvic region during intercourse • Vaginismus • Involuntary spasm of the outer third of the vaginal wall • Prevents or interferes with sexual intercourse

15. Arousal Disorders: Aging • Sexual Changes across Lifespan: • Female drop in estrogen: Interest drop; Thinning of vaginal walls; lower lubrication • Male drop in Testosterone – drop in arousal & ED • Delayed Ejaculation/Absence • Erectile Dysfunction: inability to form penile erection • Psychological cause: may experience Nocturnal erections • Medical Cause: Poor circulation/heart disease • Prostate Discomforts

16. Etiology of Sexual Dysfunctions

17. Etiology of Sexual Dysfunctions • Biological dimension • Levels of testosterone (low) or estrogens (low) linked to lower sexual interest in men and women, and erectile difficulties in men • Medications used to treat medical conditions affect sex drive • Many antidepressant and antihypertensive medications • Alcohol as leading cause of disorders – ejaculation/ed issues • Illnesses and other physiological factors (heart disease; diabetes; )

18. Etiology of Sexual Dysfunctions (cont’d.) • Psychological dimension • History of Sexual Trauma; Emotional Abuse • Increase of Stress; Poor Coping • Anxiety disorder: poor performance • Depression: anhedonia • Performance anxiety and spectator role • Cultural/Religious beliefs about sexuality/body (prohibitions) • Poor Self-Image: Negative thoughts and dysfunctional beliefs

19. Etiology of Sexual Dysfunctions (cont’d.) • Social dimension • Social relationships: positive sexual experiences • Current sexual relationship: communication/sexual compatibility; partner violence/abuse • Early sexual experiences • Traumatic sexual experiences • Relationship dynamics predictive of sexual disorders • Marital satisfaction associated with greater sexual frequency

20. Etiology of Sexual Dysfunctions (cont’d.) • Sociocultural dimension: Rigid Scripts • cultural scripts: defines roles, allowable behaviors, pleasures, sexual play script • Examples of sociocultural aspects • People in Asian countries consistently report lowest frequency of sexual intercourse • Cultural scripts for men in the United States • Sexual potency as a sign of masculinity • Homophobia toward lesbians or gays

21. Treatment of Sexual Dysfunctions • Biological interventions • Hormone replacement – testosterone, estrogen, etc. • Mechanical means to improve functioning • Vacuum pumps, suppositories, penile implants • For ED, injecting medication into penis • Oral medications (Viagra, Levitra, Cialis) • Psychological boost may lead to feelings of enhanced pleasure

22. Psychological Treatment Approaches • Education • Replace myths and misconceptions with facts • Anxiety reduction • Desensitization or graded approaches • Changing negative thoughts and beliefs about sex • Structured behavioral exercises • Tasks that gradually increase amount of sexual interaction • Sexual Communication training – relationship focused

23. Gender Dysphoria • Previously called gender identity disorder (GID) or transsexualism • Marked incongruence (mismatch) between one’s experienced or expressed gender and biologically assigned gender • Not the same as sexual orientation • Diagnosed when there is significant distress or impairment – High Suicidality Risk • Childhood – some don’t persist into adulthood • Adolescent/Adult onset - many persist into adulthood

24. Etiology of Gender Dysphoria • Etiology is unclear • Research has focused on other sexual disorders • Likely an interaction of multiple variables • Most transgender children have normal hormone levels • No specific neurological explanation • Brain alterations associated with psychosocial distress and social exclusion

25. Psychological and Social Influences • Explanations must be viewed with caution • Hypothesis – • Do Childhood experiences influence development of gender dysphoria? Mediating role? • Parent encouragement of feminine behavior, overprotection, lack of male role models, etc. • Psychosocial stressors • Stigma and lack of societal acceptance play a role in distress and impairment associated with gender dysphoria

26. Treatment of Gender Dysphoria • Gender reassignment therapies • Changing physical characteristics through hormone therapy or surgery • Many involve reconstructing genital organs • Some insurance beginning to include coverage for transgender individuals • Studies show positive outcomes

27. Paraphilic Disorders • DSM-V definition • Sexual arousal in objects, body parts, or abnormal targets (feet, lingerie, hair, voyeurism, porn, etc.) • May involve unusual erotic behavior • Diagnosed only when paraphilia harms, or risks harming others and is acted on • Or causes the individual to experience distress or impairment in social functioning

28. Paraphilic Disorders

29. Paraphilic Disorders Involving Nonhuman Objects • Fetishistic disorder – predominantly men • Extremely strong sexual attraction and fantasies involving inanimate objects • Examples: shoes or undergarments • Person is often sexually aroused to the point of erection in the presence of the fetish item • Person may choose sexual partners on the basis of having that item (e.g., bound feet) • Must cause significant distress or harm to others

30. Transvestic Disorder • Intense sexual arousal associated with cross-dressing (wearing clothes appropriate to the opposite gender) • Do not confuse with gender dysphoria • Most people who cross-dress are exclusively heterosexual • Incidence higher among men than women • Men may become sexually aroused by thoughts of themselves as female

31. Paraphilic Disorders Involving Nonconsenting Persons • Exhibitionistic disorder • Urges, acts, or fantasies of exposing one’s genitals to strangers, intent to shock • Voyeuristic disorder • Urges, acts, or fantasies involving observation of an unsuspecting person disrobing or engaging in sex activity • Diagnosed only in those age 18 or older • Individual must be distressed by or have acted on the voyeuristic urges

32. Frotteuristic Disorder • Recurrent/intense sexual urges, acts, or fantasies of touching or rubbing against a nonconsenting person • For diagnosis, person must be markedly distressed by urges or have acted on them • Prevalence is difficult to determine • Behavior may go unnoticed or presumed to be accidental

33. Pedophilic Disorder • Adult relates to children as erotic objects • Sexual abuse of children is common • Estimated 1/4 of girls and 1/5 of boys • Most people who act on pedophilic urges are friends, relatives, or acquaintances of their victims • Effects of sexual abuse can be lifelong

34. Paraphilic Disorders Involving Pain or Humiliation • Sexual masochism disorder • Sexual urges, fantasies, or acts that involve being humiliated, bound, or made to suffer • Individual does not seek harm or injury • Finds sensation of helplessness appealing • Sexual sadism disorder • Sexual urges, fantasies, or acts that involve inflicting physical or psychological suffering on others

35. Etiology and Treatment of Paraphilic Disorders • We still have much to learn • Some research findings conflict with each other • Some men may be biologically predisposed to pedophilic disorder • Psychological factors also contribute • Paraphilias may result from accidental associations between certain situations and sexual arousal

36. Behavioral Approaches to Treatment • Extinction or aversive conditioning: punishment or elimination of behavior • Acquiring or strengthening sexually appropriate behaviors: learning healthy sexuality • Developing appropriate social skills • Legal Consequences to inappropriate sexual interest

37. Rape • Sexual aggression that involves sexual activity performed against a person’s will through the use of force, argument, pressure, alcohol or drugs, or consent • Not considered a psychological disorder • Number of rapes in the U.S. has risen dramatically • One in five adult women has been raped • One in 71 men

38. Characteristics of Male Rapists • Create situations in which sexual encounters may occur • Misinterpret friendliness as provocation and protests as insincerity • Manipulate women into sexual encounters with alcohol (70%) or other drugs • Attribute failed attempts at sexual encounters to perceived negative features of the woman

39. More Characteristics of Male Rapists • Come from environments of parental neglect or physical or sexual abuse • Experience Sex earlier in life than men who are not sexually aggressive • Have more sexual partners than non-sexually aggressive men

40. Date Rape • Many Reluctant to Report • Between eight and 25 percent of female college students report having “unwanted sexual intercourse” • Many universities conducting workshops to encourage understanding that intercourse without consent is rape

41. Effects of Rape • Rape trauma syndrome symptoms • Include psychological distress, phobic reactions, post-traumatic stress symptoms, and sexual dysfunction • Phases in rape trauma syndrome • Acute phase: disorganization; PTSD Sx • Feelings of self-blame, fear, or depression • Long-term phase: reorganization • Survivors deal directly with feelings and attempt to reorganize their lives

42. Etiology of rape • Power rapist: 55 percent of rapists • Compensate for feelings of personal/sexual inadequacy by trying to intimidate victims • Anger rapist: 40 percent of rapists • Angry at women in general • Sadistic rapist: 5 percent of rapists • Derives satisfaction from inflicting pain • May torture or mutilate victims

43. Etiology of Rape (cont’d.) • Rape has more to do with power, aggression, and violence than sex • Sexual motivation also plays a role in rape • Most rape survivors are in their teens or 20s • Vulnerable age group • Most rapists name sexual motivation as primary reason for actions • Many rapists have multiple paraphilias (immature sexuality)

44. Etiology of Rape (cont’d.) • Why is the rate of rape increasing in US? • Effects of pornography and media portrayals of violent sex may affect rape prevalence • “Cultural spillover” theory • Rape is high in environments that encourage violence • United States has highest rape rate among countries reporting rape statistics

45. Treatment for Rapists • Many believe sex offenders are not good candidates for treatment • Most common penalty is imprisonment • High recidivism rates • When intervention occurs, it usually incorporates behavioral techniques • Some treatment techniques show success with exhibitionists • Outcomes tend to be poor for rapists

46. Contemporary Trends and Future Directions Trends in Defining Abnormality: • New Def: “Normal” if no harm to self or others? • Exp: Is a fetish normal if not harmful?? • Gender dysphoria may eventually be removed as a psychiatric diagnosis • Sweden has removed transvestism, fetishism, and sadomasochism from list of mental illnesses

47. Review • What are normal sexual behaviors? • What do we know about normal sexual responses and sexual dysfunction? • What causes gender dysphoria, and how is it treated? • What are paraphilic disorders, what causes them, and how are they treated? • Is rape an act of sex or aggression?

48. Group Work: Case Analysis • Each group will work together on each case, evaluate each case, form a diagnosis and develop a rationale for the decision. • Total of 4 cases representing different sexual disorders • Class Discussion • Please turn in group work at end of class