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Lecture 15

Psychology 2075 Lecture 15: Lecture 15 Sexual Dysfunction

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Psychology 2075
William Fisher

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Lecture 15 Sexual Dysfunction History of Approaches to Sexual Dysfunction • 1786: Sir John Hunter, MD, reports first treatment of erectile failure o Sends couple with unconsummated marriage, due to erectile dysfunction, to his secluded cabin, and forbids sexual contact. o “The couple were unable to follow my instructions.” o Arrange hierarchical or graded/progressive sexual interactions but forbid the anxiety provoking event = sensei focused = John Hunter • 1890-1900: Krafft-Edbing, Psychopathia Sexualis o Focus on sexual “perversions” – Appallingly Victorian o Rx: Hot iron to clitoris of masturbator • 1930-1965: Freudian psychoanalysis, psychodynamic approaches o Sexual problems are symptoms of unconscious conflict o Do not treat symptoms—identify and provide insight into their underlying unconscious conflictual basis o Multiyear iatrogenic treatment of clitoral orgasm, rapid ejaculation • 1965-1990: Masters and Johnson o Pragmatic, brief, symptom focused, behavioral therapy o Sexual problems are learned behaviors that are amenable to learned solutions o So rapid male ejaculation  rapid masturbation because you were anxious that your mom would walk in so you did it quickly • 1990-2000: Sexual vs. Marital and Relationship Therapy o disorders of sexual desire: Helen Kaplan • 1990-2000: Pharmacotherapy of Sexual Dysfunction o Sildenafil, tadalafil, vardenafil; testosterone; flibanserin; o Prior to his 1983 presentation at the American Urological association, Brindley injected his penis with an alpha-blocking smooth muscle relaxant that works as a non-specific vasodilator o “I had been wondering why Brindley was wearing sweatpants,” says Dr. Arnold Melman, chief of urology at New York’s Albert Einstein College of Medicine, who was there. “Suddenly I knew. It was a big penis, and he just walked around the stage, showing it off.” Disorders of Sexual Function: The Sexual Response Cycle – Male • Hyperactive is often introduced as an excuse for culpability in court cases but it is not an official sexual dysfunction Pain • Low sexual desire is an official sexual dysfunction Disorders of Sexual Function: The Sexual Response Cycle – Female • These can be at the level of a hassle or persistent and distressing, aka a disorder Diagnosis of Sexual Dysfunction • Desire Phase • Arousal Phase • Orgasm Phase • Coital Pain Definitions of FSD: DSM-IV-TR • Sexual AversionDisorder: Persistent or recurrent extreme aversion to, or avoidance of, all (or almost all) genital sexual contact with a sexual partner • Note: The disturbance must cause marked distress or interpersonal difficulty and must not be better accounted for by the effects of another (non-sexual) psychiatric disorder, medical disorder, or substance • Hypoactive Sexual Desire Disorder: Persistent or recurrent deficiency (or absence) of sexual fantasies and desire for sexual activity o Lets say that your marked interpersonal distress is because your partner wants to have more sex – so it may be wrong to treat you for his pleasure • Sexual Arousal Disorder: Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement o 30% said they had some difficulty lubricating or staying lubricated • Dyspareunia: Recurrent or persistent genital pain associated with sexual intercourse • Vestibulodynia: Vulvar and vestibular burning or “cutting” type of pain; may be provoked (whenever it is touched, it hurts) or unprovoked (chronic) • Vaginismus: Recurrent or persistent involuntary contraction of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted Prevalence of Sexual Dysfunction: Sexual Problems and Distress in US Women • Sexual Disorders with Distress in US Women: o Prevalence increases and distress decreases with age o Orgasmic dysfunction occurred between 2-7% of women, and peaked in the menopausal years o Desire disorders very common o The curves are steeper around menopause o This graph shows only people who are distressed (so have a dysfunction) Prevalence of Sexual Dysfunction • Female Patient Reports – London, ON ObGyn Waiting Room Series o Woman: inhibited sex desire = 47% o Partner: inhibited sex desire = 22% o Couple: frequency dissatisfaction = 23% ▪ “My sexual desire is often much lower than I would like it to be” ▪ “My partner’s sexual desire is often much lower than I would like it to be” ▪ “My partner and I often have serious disagreements about how often we want to have intercourse.” o Woman: Arousal or Lubrication problems = 28% o Woman: lack of orgasm = 35% o Woman: painful intercourse = 24% o One of more of the above = 79% o Ever discuss with MD = 16% Prevalence of Male Sexual Dysfunction: Sexual Problems of US Men, NHSLS Results • No direct measure of distress * * ED shows it is age-related Sexual Dysfunction • Often interrelated diagnoses o Desire disorder + arousal disorder • Often related to partner diagnosis o Ed (his)  HSDD (hers) = theirs Sexual Dysfunction: History I • Lifelong vs. acquired • Global vs. situational • Presentation vs. discovery History II • Predisposing Factor o Antisex upbringing, past sexual trauma • Precipitating Factor o Partner demands, new child • Perpetuating Factor – maintains the problem that emerges o Couple conflict, power struggle Sexual Dysfunction: Intake Interviews • Diagnostic Factors o Desire, arousal, orgasm, pain o Lifelong vs. acquired, global vs. situational, presenting vs. discovery o Primary complaint? Interactive couple disorder? • Personal, Sexual, Relationship, Medical History o Predisposing, Precipitating, Perpetuating Factors • Couple and Individual Interviews o Couple Dynamics? Individual Disclosures? Qualifying Information • Anything else I should know? o Incest o Fetish o Sexual Orientation Psychopathology o Substance Use o Find partner attractive? Love partner? Etiology of Sexual Dysfunction: A Bio-Psycho-Social Approach • Individual psychological problems • Interpersonal = within the couple Female and Male Desire Phase Disorders Causes • Fatigue: Bickering perpetuates fatigue, poisoning desire • Comorbid sexual dysfunction • Distractions (financial, work, school) • Pressure to participate • Liabilites (pregnancy, birth control, STI) • Past trauma • Testosterone Menopause • Hysterectomy/oopherectomy • Medications – SSRIs depress desire and sexual function Female Arousal Phase Disorder Causes • Low desire • Pressure to participate • Past trauma • Architecture of • Dislike of partner • Menopause intercourse • Performance anxiety • Hysterectomy/oopherec • Poor physical • Partner sexual tomy stimulation by partner dysfunction • Chronic illlness • Poor psychological • Sexual orientation • Medications, street stimulation by partner • Liabilites (pregnancy, drugs • Boredom birth control, STI) Male Arousal Phase Dysfunction Causes • Low desire • Performance anxiety • Anxiety • Liabilites (pregnancy, birth control, STI) • Spectatoring Condoms • Normal ageing • Boredom • Comorbid disease (vascular, neurologic, • Partner sexual dysfucntion metabolic) • Sexual orientation • Poor physical stimulation by partner • Past trauma • Poor psychological stimulation by partner • Medications, alcohol, street drugs • Pressure to participate • Hypogonadalism • Dislike of partner Male Attitudes to Life Events and Sexuality: the MALES Study Phase I: ED Prevalence and Comorbidities • Representative samples of adult male population, ages 20-75 years, in eight countries o 27,838 interviews in the US n=9,283, EU n=10,729, Mexico n=2,735, Brazil n=5,091 o Recruited via RDD or random e-mail invitation, February to April 2001 o Standardized 15-minute interview assessing men’s health issues including ED and other concerns • 16% of MALES sample self-reported erection difficulties • ED prevalence increased with age and with comorbid conditions o 30% of men in the class said they usually get an erection that lasts intercourse but not always o It is a function of age and comorbid illness o Every single male on a statin should be asked about their ED Cascade of ED Treatment Seeking • Since the advent of Viagra, we have a super effective way of fixing up ED • Why such a low amount? (16%) • Maybe it is the stigma – it is a demasculin thing • Many couples don’t talk about it • Many guys are afraid of the drug – think it will kill them • The female partner has a huge influence on this; whether she wants you to take it has a huge influence • Attribution Theory – if you attribute it to changeable factors, you won’t take Viagra More than a
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