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Chapter 17: Sexual Disorders & Sex Therapy

Sexual Arousal Disorder

  • Female sexual arousal disorder: arousal disorder where women are less responsive to arousing situations. Is listed in the DSM-5.
  • Women with this disorder tend to produce significantly lower levels of vaginal lubrication (Graham, 2010)
  • Women who enter menopause produce less lubrication also. It is believed the drop is estrogen is related to this (Rosen et al., 2012)
  • 10% of women are estimated to experience this arousal disorder.
  • If lack of lubrication is the only symptom, over the counter lubrication can alleviate the issue. Counseling is suggested if more symptoms are present.
  • Erectile Disorder/Impotency: the inability to gain or maintain an erection. We further classify the cases as either lifelong erectile disorder or acquired erectile disorder.
  • Estimated to impact 10% of men under 40. Will be present in 30% of men in their 60s (Lewis et al., 2010; Mitchell et al., 2013)
  • 37% of men report erectile dysfunction with 14% of them using medical supplements (Lindau et al., 2007). This study examined only men over 65.
  • 20% of men who take Viagra will experience no change in their erectile dysfunction.

Orgasmic Disorders

  • Premature Ejaculation: When a man reaches ejaculation much earlier than expected.
  • Measurement 1: Lasting less than 1 minute after penetration
  • Measurement 2: Lasting less than 10 pelvic thrusts.
  • Measurement 3: Personally reporting a lack of control related to orgasm.
  • Measurement 4: A person or couple reporting that they believe it is an issue

Physical Causes of Male Sexual Disorders

Physical Causes of Female Sexual Disorders

Painful intercourse & Vaginismus

  • Spinal cord injuries
  • Pelvic Inflammatory Disease/Scar Tissue
  • Has had an episiotomy
  • Allergic reactions to latex
  • Has had a hysterectomy
  • People diagnosed with severe alcoholism
  • Excessive, habitual use of marijuana (Johnson et al., 2004)
  • Antihistamines reduce vaginal lubrication
  • Older antidepressants lower sexual desire.
  • Women who have had chemotherapy for breast cancer report lower desire (Panjari et al., 2011)

Erectile Disorder

  • Heart & circulation issues
  • Diabetes Mellitus - 28% of men with diabetes are estimated to have erectile disorder (Saenz de Tajeda et al., 2004)
  • Hypogonadism: the testes produce low levels of testosterone.
  • Lower spinal cord injury
  • Stress & fatigue
  • Marijuana use increases sexual desire but decreases blood flow to penis

Premature Ejaculation

  • Prostatitis: swelling of the prostate
  • Multiple Sclerosis
  • Genetically influenced - evolutionary psychologists argue premature ejaculation is beneficial for most animals. Why?
  • Phimosis: the foreskin on a penis is unable to be pulled back. Can cause urinary tract infections and make intercourse painful
  • Almost all research related to premature ejaculation is related to vaginal intercourse.

Female Orgasmic Disorder

  • Female orgasmic disorder: also called inhibited female orgasm. Can be either lifelong or acquired.
  • Situational Orgasmic Disorder: A woman who can only have orgasms in certain situations (e.g., masturbation)
  • More common than male orgasm disorders. Around 20% of women experience female orgasmic disorder (Lewis et al., 2010)
  • Researchers are reluctant to diagnose a woman with this disorder solely due to a lack of orgasms during penile intercourse.
  • "Perhaps the woman who orgasms as a result of hand or mouth stimulation, but not penile thrusting, is simply having orgasms when she is adequately stimulated and is not having them when is inadequately stimulated."
  • Dyspareunia: genital pain during intercourse. 8% of women and 2% of men report this. It can be both physical (e.g., strained muscles) or psychological (e.g., anxiety).
  • Vaginismus: contractions and spasms of the vaginal opening and cavity. Spasms can be so strong they close the vagina.
  • Genito-pelvic pain/penetration disorder: DSM-5 combination diagnosis for either dyspareunia and/or vaginismus. Often occur together.
  • An estimated 15% of men experience premature ejaculation (Lewis et al., 2010)
  • Medications for cardiovascular disease can lower sexual desire.
  • Men are much less likely to seek therapy for premature ejaculation in comparison to erectile dysfunction.
  • Male Orgasmic Disorder/Delayed Ejaculation: A man with an erection is unable to reach orgasm.
  • Men are most likely to report they can orgasm with masturbation, but during intercourse they cannot climax.
  • Less rare than premature ejaculation.
  • When interviewed, half of the partners of people with male orgasmic disorder said they pretended to fall asleep because he was taking too long..... (Mitchell et al., 2013)

What are sexual disorders?

  • Human Sexual Inadequacy, published by Masters & Johnson (1970) is argued to be the first sexual therapy publication.
  • Sexual Disorder/Sexual Dysfunction: a symptom or behavior that causes a person distress that is often related to sexual behavior.
  • Can be physical or psychological
  • Lifelong sexual disorder: has been present since the person started having sex
  • Acquired sexual disorder: one that happened later in life.
  • How psychologists classify sexual disorders: desire disorders, arousal disorders, orgasmic disorders, and sexual pain disorders.
  • Hypoactive sexual desire (HSD): people who report a decline in sexual interest and lowered response to sexual arousal.
  • About 10% of women under the age of 49 may have symptoms of HSD. 50% of women over the age of 65 may experience symptoms (Lewis et al., 2010)
  • Discrepancy of sexual desire: often confused as HSD. This is when the expectations or desires of sexual frequency do not match up in a relationship. The one who wants more sex may say something "is wrong" with the one who wants less sex.

Psychological Causes of Sexual Disorders

  • Prior learning - has received social punishment in youth related to sexual activities
  • Anxiety related to fear of failure (called performance anxiety)
  • Cognitive interference: distraction during sex. Usually focused on worries related to performance (e.g., "Am I Doing This Right?", "Do I Look Sexy Enough?", "Do they think that I'm a freak?")
  • Spectatoring: Coined by Masters & Johnson. This is when you verbally judge your partner during sex. The person who experiences it may develop sexual disorders.
  • Failure to communicate
  • Lack of sex education (e.g., does not know where or what the clitoris is)
  • Their first sexual experience was negative and they are now anxious about sex encounters
  • Child sexual abuse, particularly by parents
  • Strong belief that "sex is a dirty and sinful act that should only be used for procreation"

The New View of Women's Sexual Problems

  • The New View are sex therapists who disagree with the DSM's classification of sexual disorders
  • Argument 1: Women and men respond to sex differently, therefore we should not measure them identically.
  • Argument 2: They tend to focus on one person in a two-person activity.
  • Argument 3: Little discussion about how intimacy influences sexuality (i.e., stop comparing married couples to single people having sex)
  • Depression
  • These therapists have added additional issues related to sexual disorders
  • Problems related to culture, politics, and income: 1) lack of sex education in their culture, 2) birth control or abortion is not legal, 3) too tired from working a lot of hours
  • Problems related to partner and/or relationship: 1) Anxiety about relationship, 2) different levels of arousal, 3) lack of sexual communication, 4) conflict in other areas, 5) partner's health
  • Problems related to psychological or physical issues: 1) sexual aversion, 2) attachment and intimacy issues, 3) fear of pregnancy or STI, 4) physical limitations, 5) side effects

Therapies for Sexual Disorders

Behavioral Therapy

  • Desensitization: the process by which therapists remove a person's conditioned phobia by gradually exposing them to their fear. Sometimes referred to as "exposure therapy".
  • Behavioral sex therapy is focused on arguing that people have learned ineffective sexual behaviors instead of diagnosing the client with an illness.
  • Goal-Oriented Sex: therapists strongly encourage people to avoid this. This is sex where the main focus is having an orgasm.
  • Sensate Focus exercises: the couple is "forbidden" to have intercourse and can only participate in sensate exercises.
  • This approach is less likely to report "it's all the woman's fault"
  • Behavior Therapy
  • Goal 1: allows the couple to learn what arouses each other
  • Goal 2: encourages effective communication during sex
  • The sensate process: one couple is the "giver" and the other is the "receiver". The giver is to stimulate their partner's body with just touch. The receiver is to tell their partner what they like or do not like. In the first few sessions you avoid genital touching and slowly build up to that during later sessions.
  • Sensate focus exercises work on all forms of couples, heterosexual or homosexual
  • Cognitive-Behavioral Therapy

Couple's Therapy

  • Treating performance anxiety is the most common starting point.
  • Encourages the couple to broaden their sexual scripts
  • Educate couples on how to leave conflict out of the bedroom OR resolve said conflict.
  • Help couple become aware how they developed problems initially. A way to avoid it happening again (i.e., relapse)
  • Stop-Start Technique: treatment of premature ejaculation.
  • Couple's therapy
  • The partner that does not have premature ejaculation will stimulate the partner with the issue. Once he has an erection, the partner stops stimulation. They now wait for him to lose his erection. Repeat the process for 15-20 minutes.
  • Women who are unable to have an orgasm, they are encouraged to start masturbating (Graham, 2014)
  • Kegel exercises: exercises that strengthen muscles in the side of the vaginal opening.
  • Focused on strengthening pelvic floor muscles, primarily the pubococcygeal muscle (PC muscle)
  • The easiest way to start is to try to flex the muscles used to urinate. Increases chance of orgasm in women and increases stamina in men

Biomedical Therapy

  • The original Viagra required men to inject the medicine directly into their urethra right before sex....
  • Viagra has never been reported to increase sexual functioning, even though men tend to believe this.
  • The FDA has rejected over 10 different forms of female Viagra. The rejections range from serious side effects to lack of evidence in effectiveness.
  • Biomedical therapy
  • Some women have reported just because their husband now has a long-lasting erection, it doesn't make him a better lover (Montorsi & Althof, 2004)
  • Penis Pumps: silly name, but relatively effective. Men with diabetes tend to respond to this treatment.
  • Viagra and Penis Pumps are covered by medicare, birth control is not.....
  • Penile Prosthesis: Penis implant or transplant. A man has two saline sacs planted into his abdomen. When he wants to have sex he pumps the fluid from his abdomen into the penile prosthesis. Typically used for men that have had penile cancer or serious injuries.
  • The same process can be used for female to male transgender people
  • Dual Control Model: people high on inhibition and low on excitation are more likely to report sexual disorders (Bancroft et al., 2009)
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