Chapter Outline (See related pages) Defining Sexual Disorders Western culture's social morality influenced by religion and sexology Definition of sexual normality helped guarantee survival of human species and the family Direction of sex drive influenced by socialization Human sexual behavior viewed across culture is extremely variable Within culture, attitudes toward sexuality may change over time Sexual behavior does not necessarily conform to declared standards of sexual morality or normality Social climate of 1960s and 1970s questioned traditional sexual morality American Psychiatric Association dropped homosexuality from list of psychological/psychiatric disorders in 1973 Research suggests that there might not be justification for regarding homosexuality as a pathological pattern Sexual Dysfunction Our society has had two upheavals regarding sex Sexual revolution of 1960s and 1970s and openness about sex Spreading of AIDS by casual sex Forms of Sexual Dysfunction Sexual dysfunctions are disorders involving disruption of sexual response cycle or pain during intercourse Research of Masters and Johnson led to better understanding of sexual dysfunction Sexual Desire Disorders First phase of sexual response cycle is desire phase Hypoactive Sexual Desire Disorder Hypoactive sexual desire disorder refers to lack of interest in sexual activity even in sexual fantasy Low desire defined within context of age, gender, and cultural norms Biological factors include pain, illness, and reduced testosterone Psychological factors include depression, stress, ambivalence about sex and conflict in relationship Is most common complaint of couples seeking treatment for sexual dysfunction Sexual Aversion Disorder Sexual aversion disorder characterized by lack of interest in sex and disgust or fear of sex Related to sexual trauma, dyspareunia Sexual Arousal Disorders Arousal is second phase of sexual response cycle Female Sexual Arousal Disorder Female sexual arousal disorder related to insufficient vaginal lubrication Few known biological factors Psychological factors include emotional distress, sexual trauma, and lack of trust Male Erectile Disorder Male erectile disorder formerly known as impotence Related to multiple causes Age and medical conditions, substance abuse are factors Psychological factors include performance anxiety, stress, depression Orgasmic Disorders Third phase of sexual response cycle is orgasm Female Orgasmic Disorder Female orgasmic disorder involves woman having trouble reaching orgasm Common causes include other sexual problems, inadequate sexual stimulation, and anxiety about sex Antidepressant drugs becoming more frequent cause Male Orgasmic Disorder Male orgasmic disorder is male's inability to reach orgasm May be caused by antidepressants and problems letting go with partner Premature Ejaculation Most common complaint is premature ejaculation, which is reaching orgasm too soon May be due to both psychological and biological causes Sexual Pain Disorders Dyspareunia Dyspareunia is pain during sexual activity Usually due to gynecological or urological problems Vaginismus Vaginismus involves contraction of muscles that surround outer part of vagina Muscles contract causing pain during intercourse Often related to sexual trauma Diagnosing Sexual Dysfunction Lifelong dysfunction refers to problem existing since earliest sexual experiences Acquired dysfunction refers to problem that develops after normal functioning Generalized dysfunction refers to dysfunction present in all sexual situations Situational dysfunction refers to dysfunction present in some sexual situations or with some partners Term sexual dysfunction must meet criteria Dysfunction diagnosed with evidence that dysfunction causes marked distress or interpersonal difficulty Dysfunction must persist over time One failure often creates anxiety, which impairs sexual responsiveness on next occasion Groups at Risk for Sexual Dysfunction More education and money person has, less at risk Racial and ethnic differences Prevalence varies with gender Sexual Dysfunction: Theory and Therapy The Psychodynamic Perspective Sexual dysfunction attributed to unresolved Oedipal conflict Current approach views sexual dysfunction as disturbance in object-relations Therapy involves uncovering conflict and working through it The Behavioral and Cognitive Perspectives Learned Anxiety and the Spectator Role Early respondent conditioning in which sexual feelings paired with shame, disgust, and anxiety over possible failure seen as central Painful experiences cause person to worry and assume spectator role Spectator role caused by several factors Assessment Assessment important for treatment and takes into account all relevant factors Sexual script developed to describe who does what to whom, and what thoughts, emotions, and sensations each associates with sex Attitudes, patterns of sexual arousal, and sexual trauma part of assessment Direct Symptomatic Treatment Couple is retrained to experience sexual excitement without performance pressure Training is in form of sensate focus exercises Allow partners to rediscover sexual response without anxiety Improve communication by providing feedback Start-stop and squeeze techniques used in premature ejaculation Paradoxical instruction used in erectile disorder Education and self-exploration exercises used to treat lifelong orgasmic dysfunction in women Sexual aversion disorder treated with systematic desensitization Cognitive Psychology and Direct Treatment Masters and Johnson used direct treatment of sexual dysfunction with emphasis on the couple Cognitive approach focuses on mental processes underlying sexual response and attitudes and beliefs hostile to sex C. Multifaceted Treatment Kaplan: Remote Causes Kaplan argues that sexual dysfunction caused by immediate and remote causes Immediate causes include performance anxiety, poor technique, and poor communication Remote causes include intrapsychic conflicts Combined direct treatment and psychodynamic treatment into psychosexual treatment Remote causes ignored as long as patient is responding to immediate causes Remote causes may prevent patient from responding Direct therapy brings to surface psychological problems Family Systems Theory: The Function of the Dysfunction Masters and Johnson see patient as the couple Sexual dysfunction has function in couple's total relationship Questions about power and control may be related to sexual dysfunction Secret payoffs may underlie sexual dysfunctions and must be dealt with 3. Results of Cognitive-Behavioral Direct Treatment Outcomes may not match outcomes of Masters and Johnson's therapy Research in early stages for many treatments of sexual dysfunction Group therapy may be useful for some dysfunctions Combining relationship therapy with direct treatment may be beneficial The Neuroscience Perspective Some cases of sexual dysfunctions caused by organic factors Diagnostic tools used to differentiate between psychological and organic sexual dysfunctions Most sexual dysfunctions involve both psychological and physiological factors Biological treatments have focused on erectile disorder Vacuum pump used for enhancing erections Injecting a vascular dilation agent Using a vasodilator The drug called Yohimbine stimulates secretion of norepinephrine Penile prosthesis is available Oral medications are available; they act on the tissues of penis itself Trend is to integrate biological and psychological treatments Paraphilias Recognized patterns that deviate from standard are called paraphilias Distinction made between paraphilias that involve harm to others and those that are victimless When pattern or object becomes central focus and sine qua non of person's arousal and gratification, then pattern is considered abnormal Fetishism Fetishism--reliance on inanimate objects or on a body part to exclusion of person as a whole for sexual gratification Example of spectrum disorder Exclusive fascination with inanimate object is known as partialism Most fetishes associated with human body such as fur, women's stockings, shoes, and underpants Transvestism Transvestism--sexual gratification through dressing in clothes of opposite sex After cross-dressing, transvestite masturbates or has heterosexual intercourse As a group, transvestites no more prone to psychological disturbances than general population Most lead quiet, conventional lives Transvestism confused with other forms of cross-dressing Cross-dressing for sexual pleasure is transvestism Cross-dressing to assume a female role (e.g., drag queens who are typically homosexual; entertainers as part of performance) is not transvestism Often confused with transsexuals who have gender identity disorder Related disorder is autogynephilia, in which man depends for sexual arousal on the fantasy of being a woman Exhibitionism Exhibitionism--sexual gratification through display of one's genitals to involuntary observer Most exhibitionists are not dangerous Typical exhibitionist is young man, sexually inhibited, and unhappily married Gratification is derived from women's shock, fear, and revulsion and then from masturbation In some cases, exhibitionism is symptom of more pervasive disturbance Most exhibitionists are shy, submissive, immature men who experience feelings of social and sexual inferiority and doubt their masculinity Exposing genitals gives them sense of masculine power Best cure for exhibitionist is not to respond to it Voyeurism Voyeurism--sexual gratification through clandestine observation of other people's sexual activities or sexual anatomy Often occurs alongside normal sexual interest Must take into account invasion of person's privacy Risk involved in watching strangers is important to gratification Voyeurism provides substitute gratification and reassurance of power Most voyeurs are harmless Sadism and Masochism (S & M) Sadism--sexual gratification through infliction of pain and/or humiliation on others Masochism--sexual gratification through pain and/or humiliation inflicted on oneself Terms named after literary figures who wrote about physical and psychological cruelty Degree of cruelty ranges from sticking person with pin to mutilation Sadomasochistic relationship seen in complementary partners Most sadists and masochists are heterosexual, well educated, affluent, and undisturbed by their sexual activities Drawing line between normal and abnormal may be difficult DSM-IV requires evidence of distress of interpersonal difficulty Many are satisfied with their sexual patterns Frotteurism Frotteurism--sexual gratification through touching and rubbing against a nonconsenting person Frotteurs operate in crowded places where they can escape easily Sense of power over unsuspecting victim is important Pedophilia Pedophilia--child molesting Involves serious violation of child's right; child may suffer serious psychological harm About 10-15% of children and adolescents are victims Most pedophiles are male Appears to be law-abiding and escapes detection Most are acquainted with victim and his/her family and may be related to victim Molestation usually does not include physical violence but persuasion using authority Molestation occurs in repeated incidents with same child Pedophilia usually accompanied by other paraphilias Two types of molesters Situational molesters More or less normal Have heterosexual histories and prefer adult sexual partners Molestation is impulsive and usually response to stress Incest offenders usually this type Preference molesters Prefer children as sexual partners, usually male children Do not view their behavior as abnormal Child molesting is regular sexual outlet and planned Have a higher recidivism rate Causes of pedophilia are varied May be arrested psychological development Early experience of arousal with other children Attempt to reenact their histories of molestation Children do not report their victimization immediately Child victims report sleep and eating disorders and phobias and fears Adults who were victimized as children report depression, self-destructive behaviors, and distrust of others Some types of child abuse seem to be more harmful Abuse at early age Continuing over long period of time Close relationship with pedophile Violent or severe abuse Incest is sexual relations between family members Rate of incest is 7-17% Victims of fathers report more harm than other perpetrators Abuse by father or stepfather more damaging Typical incestuous father limits extramarital sexual contacts to daughter or several daughters Tend to be highly moralistic Father-daughter incest occurs in troubled marriage Wife is often isolated from other family members Daughter may assume caretaking role in family Long-term effects on daughter are profound Paraphilias: Theory and Therapy The Psychodynamic Perspective Oedipal Fixation Paraphilias are continuation into adulthood of diffuse sexual preoccupations of child Paraphilias result of fixation at pre-genital state resulting in castration anxiety Transvestism seen as denial of mother's presumed castration Sadism is seen as attempt to take part of castrator to relieve anxiety Other psychodynamic theories suggest role of person's inability to disentangle and control basic id impulses Group and Individual Therapy Usual procedure is to uncover conflict by working through it Group therapy places individual in situation where he learns he is not the only one Research suggests that psychodynamic therapy to be ineffective The Behavioral Perspective Conditioning Deviation results from respondent-conditioning process, whereby early sexual experiences are associated with unconventional stimuli Sadism and masochism involve failure to learn to discriminate among types of arousal Deviations may be due to child being cuddled by parents only after being punished, pairing physical affection with punishment Unlearning Deviant Patterns Multifaceted approach combines psychotherapy with techniques to change arousal patterns Goal is to change sexual arousal patterns, beliefs, and behaviors First step is to bring deviant sexual behavior under temporary control Behavioral techniques used to eliminate deviant approach Stimulus satiation Covert sensitization Shame aversion therapy Treatment attempts to build appropriate sexual orientation and includes training in social and sexual skills Trend toward relapse prevention training The Cognitive Perspective Learning Deviant Attitudes Way sex drive is expressed depends on childhood attitudes Sex offenders tend to objectify their victims as sources of gratification rather than as human beings Combating Deviant Beliefs Procedures is to identify deviation-supporting beliefs, challenge them, and replace them with appropriate beliefs Many programs include training in victim awareness whereby they are confronted with emotional damage done to victims Another technique is role reversal The Neuroscience Perspective Deviations may be related to neurological disorders Studies have inconclusive results Castration, drugs, and brain surgery have been used Changes in deviant arousal in laboratory may not generalize Treatment Efficacy Research and reviews ontreatment efficacy for these disorders have been mixed. Recidivism for many of the parahilias remains high. Some treatment methods show promise. Gender Identity Disorders (GID) Gender identity disorders (GID) characterized by sense that one's true gender is opposite of one's biological gender GID defined by two features Gender dysphoria is unhappiness with one's own gender Desire to change to other gender Cross-dressing known since ancient times Transsexual refers to people seeking to change gender by means of hormones or surgery Patterns of Gender Identity Disorder Homosexual male-to-female transsexuals Homosexual female-to-male transsexuals Heterosexual male-to-female transsexuals GID can affect people of all ages Most children who have desire to be opposite do not grow up to be transsexual adults The Psychodynamic Perspective GID seen as disturbance in parent-infant bond Males said to be in overlong, symbiotic relationships with mother, creating a female identity in infant Females identify with father instead, because of mother's physical or emotional absence Some argue that psychoanalysis is not appropriate since opposite-sex parent part of core identity and cannot be changed The Behavioral Perspective GID is caused by gender role behavior being shaped toward opposite sex by caretaker Treatment involves stopping reinforcement for cross-dressing behavior and providing reinforcement for gender-appropriate behavior Another idea suggests that GID is result of imprinted gender fixation The Neuroscience Perspective Hypothesis suggests GID due to hormone imbalance Difference in brain also believed to be involved Gender Reassignment One solution is to change the identity to fit body Alternative is to change body to fit identity in process called gender reassignment Process involves steps Undergoes detailed evaluation by mental health professional At least three months of psychotherapy Hormone treatments to initiate physical changes In real-life test, individual must live completely in desired gender for at least one year Last phase is surgery Outcomes of gender reassignment surgery is improvement or satisfaction in two-thirds to nine-tenths of patients Some regretted surgery, having serious psychological breakdowns Outcomes of surgery influenced by several factors The longer the patient is kept in real-life test and the more realistic the expectations, the better the outcome Female-to-male reassignment yields more satisfaction Person's prior psychological health also predictor of success
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