Desire Deconstructed: Unravelling the complexities of Sexual Desire

1. Desire Deconstructed:Unravelling the complexities of Sexual Desire Dr Allyson WaiteClinical Psychologist

2. Programme • Introduction and Background • Definitions – What is Sexual Desire? • Biopsychosocial factors - The development and expression of Sexual Desire; • When desire becomes a difficulty – Models of conceptualising disorder of desire; Gender issues • Assessment : Individual/Couple factors • Exercise – role play • Treatment Issues – Sensate Focus • Discussion and Questions

3. Two contrasting experiences of Desire…? • Poems: • “Autumn” • “I’m lying on the right side of the bed”

4. The Unarticulated Fundamental Questions (Kleinplatz) • What is the basis/origin to sexual desire? • Are all people capable of some kind of sexual feeling? • To what extent are fantasies, desires or preferences subject to change?

5. Desire in context • Von Krafft-Ebbing 1886 – sexual drive as “physiological law” • 19thC – sexual abstinence and chastity virtuous; women - pure, asexual & respected for their lack of sexual response. Control and inhibition of sexual drive. • Early 20thC: Women seen as innately passive – needing greater male appetite to elicit their sexual response. • Freud’s concept of libido > than sexual drive • 1960/s – Masters & Johnson 4 stage sexual response model – physiology of normal sexual response – interactive nature of sexual response but desire absent. • Behavioural focus, anxiety, • 1970’s – Kaplan – Desire as deficient form above model. • Psychodynamic and relationship focus • 1990’s – medicalisation of sex therapy

6. Definitions • Working Definitions: • “…A subjective state characterised by a predisposition to seek out sexual stimuli” (Bancroft 1983) • “A sum of forces that inclines us towards and away from sexual behaviour” (Levine, 2002) • “An interest in being sexual and in having sexual relations by oneself or with an appropriate (mutually consenting) adult” (Wincze & Carey, 2001) • Distinct from – sexual identity, sexual behaviour

7. Biological • Sex Drive: • Biological underpinnings in the cerebral cortex, limbic system and endochrine system (Rauch et al, 1999) • Neural structures for regulating and modulating sexual desire in the hypothalamus (somatic components) and limbic system (emotional components) • Limbic system can moderate our sexual interest in response to our psychological state at the time • Sexual drive influenced by levels of sex hormones – estrogens and androgens (women) and androgens (men) which act on the brain and peripheral organs

8. Biological factors • Gender differences • Age • Illness/disease • Medications etc

9. Aline Zoldbrod, (1998)

10. Psychological • Self perception, Self esteem, Self worth, Body image • Attachment experiences • Capacity for intimacy • Individuation/Differentiation • Attitudes, expectations, aspirations, beliefs, anxiety • Past experiences and sexual history • Sexual abuse - anxiety, shame, guilt, dissociation • Life stage issues • Life events • External circumstances/stresses

11. Relational • Strong relationship between relationship satisfaction and sexual desire but Is it cause or effect? • Greater satisfaction in the relationship = greater intimacy = greater desire OR lack of desire = less intimacy (emotional and sexual) = less satisfaction • Relationship distress as both a causal determinant and outcome of low sexual desire in studies • Specifically communication of needs and desires, emotionally and sexually , balance of power, sharing of tasks • Discrepancies in desire and negotiation • Life events/Life stage issues for the couple – bereavement, separation, childbirth, fertility issues • Dependency vs autonomy, mutuality vs differentiation

12. Sexual/Emotional Intimacy paradox • Emphasis on interpersonal factors • Sexual paradox – decrease in sexual intimacy with increase in emotional intimacy • Sexual intimacy process throughout which desire is created, blocked, reprocessed and recreated in lasting way. Problems can occur at any stage • Conflagration • Merger • Fusion • Differentiation • Integration

13. Socio-cultural • Messages internalised on what it means to be sexual, what is accepted and not • Shapes a person’s willingness to know about and express sexual self and their attitudes to sex • Family, education, religion, societal, cultural and political, age • Gender roles and stereotypes/messages

14. Esther Corona Aspects of Sexual IdentityWAS 2007 Body Reproduction Interpersonal Bonds Gender Identity, intimacy, diversity Eroticism, desire, pleasure Power, sexual citizenship

15. Levine – Biopsychosocial model • Generated & influenced by an interaction between internal and external factors • Neuroendochrine system – biological drive • Cognitive and Emotional Processes – wish to behave sexually • Psychological processes - motivation and willingness to behave sexually • Sexual desire fluctuates within individuals • “Voice” and “Barometer” - • Sexual desire -Dilemmas, Paradoxes, Conflicts

16. Traditional models of sexual function • Masters and Johnson • Model of physiology of normal sexual response • Linear process • Hydraulic - sexual urge is a force which builds up and requires a release. • Emphasis on mechanics and performance • Sexual Drive - spontaneous force which triggers arousal • Male model of sexual function?

17. Orgasm Sexual Excitement Resolution Arousal Desire Time Traditional Human Sex Response Cycle

18. Emotional Intimacy Needs Seeking out & being receptive Sexual Stimuli Enhanced Intimacy Spontaneous Sexual Desire Emotion & Physical Satisfaction Biological & Psychological factors Arousal & Sexual Desire Sexual Arousal To Continue Alternative Female Sex Response Cycle

19. Basson • Intimacy based model of sexual motivation • Circular rather than linear causality • Each phase sexual and non sexual affecting and affected by the previous one • Sexual response cycle is biopsychosocial • Receptive model and dependent on stimuli and context rather than spontaneous drive • Cycle affected by safety, privacy, physical, emotional wellbeing, familly lifecycle/tranisions • Past negative sexual expreinces, low self image, fear of negative evaluation from partner, pain, poor body image • Stimuli and content are processed by the mind and depending on outcome may proceed to arousal • Enjoy, indifference, dysphonic, dissociative or ending stimulation • If enjoyment, stimulation continues to point of arousal, without either negative thoughts or emotions, desire accessed, further arousal and orgasm may occur • Achieve greater emotional intimacy and sexual satisfaction • If stimuli experienced as emotionally negative even if arousal/desire accessed – intimacy not enhanced and cycle disrupted, decrease motivation

21. Prevalence of Desire Disorders • HSDD: 30% women, 15% men. Rosen, R (1996) Current Psychiatry Reports Vol2(3) • 27 - 33% of US women in a non clinical population aged 18 – 59 (Michael et al, 1994,Lauman et al 1999) • 30-50% of women report low desire (Basson, 2001) • 1 in 3 women, 1 in 6 men uninterested in sex • 1 in 5 women, 1in 10 little pleasure from sex (NHSLS survey, Laumannet al, 1994),

22. Desire disorders: Hypoactive sexual desire disorder. Sexual aversion disorder. Arousal disorders: Male erectile disorders Female arousal disorder Male orgasmic disorder Female orgasmic disorder Early ejaculation Pain Disorders: Vaginismus Dyspareunia Paraphilias: exhibitionism, fetishism, frotteurism, pedophilia, masochism, voyeurism etc. Subtypes: lifelong /acquired. generalised/situational. Psychological factors/ combined factors DSMlV Categories of Sexual Dysfunction

23. DSM-lV:Hypoactive Sexual Desire Disorder • A. Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgement of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as the age and context of a person’s life. • B. The disturbance causes marked distress or interpersonal difficulty • C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the effects of a substance or a general medical condition. • Subtypes: • Lifelong/Acquired • Generalised/Specific • Psychological/Combination

24. DSM-lV:Sexual Aversion Disorder • A. Persistent or recurrent extreme aversion to, avoidance of all (or almost all) genital sexual contact with a sexual partner • B. The disturbance causes marked distress or interpersonal difficulty • C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) • Subtypes: • Lifelong/Acquired • Generalised/Specific • Psychological/Combination

25. Excess of Desire • Excessive Sexual Desire not recognised in DSM as sexual desire disorder • OOCSB – sexual addiction, hypersexuality, compulsivity • Same factors that diminish desire in some individuals can increase it in others: • Attempting to meet emotional need through sex – temporary relief and comfort but self destructive • Mental state, drug induced, paraphillias, childhood abuse and trauma, ADD, emotional regulation deficits and impaired capacity for emotional intimacy, loneliness,

26. Women’s Sexual Problems: a new classification Tiefer et al (2001) • Sexual problems resulting from socio-cultural, political or economic factors. • Ignorance & anxiety resulting from inadequate sex education etc. • Sexual avoidance or distress caused by perceived inability to meet cultural norms. • Inhibitions caused by conflict. • Lack of interest because of other obligations. • Sexual problems relating to partner and relationship. • Betrayal. • Discrepancies in desire • Not being able to ask for what you want. • Resentment or conflict over other matters. • Partners health or sexual problems interfering with sexual desire. • Sexual problems resulting from psychological factors. • Aversion or desire problems because of past abuse. • Fear of consequences of sex. • Sexual problems resulting from medical factors.

27. Willingness requires: Positive attitude towards self, partner and towards sex. An adequate sense of wellbeing Desire requires willingness plus Drive – biological component, occurs spontaneously yet is still subjective. Can be affected by drugs, physical illness, emotional state, learning, stage of menstrual cycle. Motivation – comes from: sexual identity – image of self as sexual being quality of non-sexual relationship reasons for sexual behaviour transference from past attachments. Aspiration – wish to have/not have sex comes from beliefs about sex. Arousal requires enough of the preceding plus: Awareness of arousal in own body Willingness and/or ability to refrain from self-distraction and to make arrangements to avoid external distractions. Positive expectations and past experiences Sufficient stimulation Orgasm requires enough of the preceding plus: An understanding of basic anatomy and physiology. Visual and tactile experience of own body’s responding. Sexual skill competence. Satisfaction requires varying amounts of the preceding plus: A feeling of intimacy and closeness with partner, that comes from feeling understood, valued and cared for. Sexual self esteem: feeling deserving of receiving and giving sexual and sensual pleasure and love. An ‘enjoyable enough’ sexual experience. Individual Sexual Response Model

28. Case Example

29. Assessment • Jigsaw puzzle • Breadth – “wide before deep” • Sex in context – personally and relationally • Assessment of sexual issue – current, past, • Personal history • Sexual history • Relationship history • Process vs Content

30. Full description of the problem from BOTH partners’ perspectives: who, what, why, when, how? Ask both partners their thoughts, feelings and expectations about the situation. Essential clarificatory questions: “Has this happened since you started having sex or only in recent times?” “Does it happen every time or only in some situations?” Couples and individual assessment needed. Assessment Questions

31. Assessment exercise

32. Treatment • Formulation driven • Tailored to the needs of individual/couple • One size doesn’t fit all • Multi-dimensional & Eclectic • Treatment approach shifting focus from: • Genitals to whole body • Physical function to emotional, psychological, interpersonal • “Mechanics”/performance to enhancing the capacity for sensuality, intimacy, relatedness • Process issues

33. Sensate Focus • Aimed at heightening awareness of erogenous zones • Agreed ban on intercourse honour pursuer role explain need to remove pressure establish responsibility for own sexual needs check comfort with masturbation – own/partner • Set appropriate parameters: non sexual touching length and frequency of sessions setting the scene • Agreement on types of touching • Feedback guidelines

34. Sensate focus • Whenever one partner has withdrawn from sex: Pressure problem – separates non sexual from sexual touching Lack of desire/arousal problem – can help individuals to re-experience or experience for the first time Avoids waiting for Spontaneous desire to occur Resuming intimacy – rebuilding trust, communication about sex

35. Sex Therapy New Zealand Ltd • Training Institute • Online course, downloadable audio/written resource: Managing Sexual Dysfunction for Medical Practitioners. • Multi-disciplinary Foundation Course. • Advanced Training in Sex Therapy. • National Referral Network • Accredited sex therapists nationwide. • Online consultations. • www.sextherapy.co.nz 0800 sex therapy (0800 739843) admin@sextherapy.co.nz

36. References • Anders, S., Chernick, A., Chernick, B., Hampson, E. & Fisher, W. Preliminary Clinical Experience with Androgen Administration for Pre and Post Menopausal Women with Hypoactive Sexual Desire, (2005) Journal of Sex and Marital Therapy, 31, 173-185 • Basson, R. Using a Different Model for Female Sexual Response to address Women’s Problematic Low Sexual Desire. Journal of Sexual & Marital Therapy, (2001), 27, 395-403 • Basson, R. Biopsychosocial models of women’s sexual response: application to the management of desire disorder’s, (2003), Sexual and Relationship Therapy, 18, 1, 107-115e • Gehring, D. Couple Therapy for low Sexual Desire, Journal of Sex and Marital Therapy, (2003) 29, 25-38 • Kaschak, E. & Tiefer, L. (2001) A NeKleinplatz, P.J. (Ed.). (2001). New Directions in Sex Therapy: Innovations and Alternatives. Brunner-Routledge, USA and UK. • w View of Women’s Sexual Problems. Haworth Press Inc. US.

37. References • Leiblum, S. R. (2002).Reconsidering gender differences in sexual desire: an update. Sexual & Relationship Therapy”, 17, 1, 57-68) • Levine, S. Reexploring the concept of sexual desire. Journal of Sex & Marital (2002) Therapy, 28, 39-51 • Lobitz W & Lobitz G. Resolving the Sexual Intimacy Paradox: A developmental model for the treatment of sexual desire disorders (1996), Journal of sex and Marital Therapy, 22, 2, 71-84 Schnarch, D. (1997). Passionate Marriage. W.W.Norton, U.S.A. • Schachner and Shaver (2002) in Johnson, S.M. & Whiffen, V.E. (Eds.) (2003) Attachment Processes in Couple and Family Therapy. Guildford Press, N.Y. • Zoldbrod, A.(1998). Sex Smart: How Your Childhood Shaped Your Sexual Life and What to do About it. New Harbinger Publications, US.