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Chapter 16

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Chapter 16 Sexual dysfunctions • Definition: involve problems in experiencing sexual arousal or in carrying through with a sexual act to the point of sexual satisfaction • Sexual response cycle: Masters and Johnson; five phases o Desire: urge to engage in any type of sexual activity o Arousal: excitement phase; psychology experience of arousal and pleasure and two physiological changes  Vasocongestion: filling of blood vessels and tissues with blood; engorgement; erection of penis caused by increased flow of blood to arteries of penis and decrease in outflow of blood through veins; enlarging of clitoris, swelling of labia and moistening of vagina  Myotonia: muscular tension; will culminate in orgasm o Plateau: excitement at a high but stable level; pleasurable in itself; feelings of tension, flushing, salivation, heavy breathing, obliviousness to external stimuli o Orgasm: discharge of neuromuscular tension built up in previous phases; sense of inevitability prior to orgasm; rhythmic contractions of the prostate, seminal vesicles, vas deferens, penis and urethra and ejaculation of semen; rhythmic contractions of orgasmic platform and more irregular contractions of the uterus  Refractory period: follows ejaculation in males; cannot achieve full erection and another orgasm; lasts from a few minutes to several hours; becomes longer with age; women don’t have this and so are capable of experiencing multiple orgasms o Resolution: entire musculature of body relaxes; state of deep relaxation; loss of erection and subsiding of orgasmic platform • Distinctions: sexual arousal in women more about mental excitement; greater variability in female pattern; great variation in length and distinctiveness; occasional transient problems in sexual functioning common so difficulty must be recurrent and causing distress/interpersonal trouble for diagnosis • Sexual desire disorders: lack of desire for sex most common complaint of people seeking therapy; desire manifested in fantasies, interesting in initiating or participating in sex and awareness to sexual clues from others; originally seen as simple consequence of other dysfunctions; falls into two categories o Hypoactive sexual desire disorder: persistent lack of sexual fantasies and desire for sexual activity; in most cases, individual used to enjoy sex but has lost interest; not given if lack of desire is result of transient circumstances (ex: too busy/fatigued) or another problem in sexual functioning; can be generalized or specific; far more women report low sexual desire;  Generalized SD disorder: little desire for sexual activity for most of life  Situational SD disorder: lacks the desire to have sex with their partner but has sexual fantasies about other people o Sexual aversion disorder: persistent and extreme aversion to genital sexual contact with a sexual partner; may feel sickened by sex or experience acute anxiety; some people experience a generalized aversion to all sex activities • Sexual arousal disorders: do not experience the physiological changes that make up the excitement or arousal stage of the sexual response cycle o Female sexual arousal disorder: recurrent inability to attain or maintain the swelling-lubrication response of sexual excitement; much less known about this; reported in about 20% of women o Male erectile disorder: recurrent inability to attain or maintain an erection until the completion of sexual activity; often referred to as impotence; occasional problems very common; only 4-9% warrant diagnosis of disorder  Lifelong: never been able to sustain erections for a desired period of time  Acquired: able to sustain erections in the past but no longer can • Orgasmic disorders: two types o Female orgasmic disorder: anorgasmia; recurrent delay in or absence of orgasm following sexual excitement despite receiving adequate stimulation; ¼ women have problems reaching orgasm; greater in postmenopausal women; no physical evidence of orgasm in women so harder to gauge o Premature ejaculation: inability to delay ejaculation as desired; most common form of orgasmic disorder in men; minimal sexual stimulation; often called rapid ejaculation because of difficulties in defining premature; three components to its determination: subjective sense of ejaculating too quickly (behavioural), worry or concern over latency of ejaculation (affective) and reflection of having little control (efficacy); resort to math, multiple condoms, masturbating before sex, etc o Male orgasmic disorder: recurrent delay in or absence of orgasm following sexual excitement; cannot ejaculate during intercourse but can with manual/oral • Sexual pain disorders: two types o Dyspareunia: genital pain associated with intercourse; rare in men but 10- 15% of women report it; shallow pain during intromission (penis insertion) or deep during thrusting; can be the result of dryness caused by drugs, clitoral or vulval infection, vagina irritation or injury or tumours of internal reproductive organs; in men involves painful erections or pain during thrusting o Vaginismus: in women, involuntary contractions of the muscles surrounding the outer third of the vagina when vaginal penetration is attempted; may experience sexual arousal and have orgasms when clitoris is stimulated; 5-17% experience this; DSM does not require experience of pain for diagnosis • Causes of sexual dysfunctions: most common cause of one sexual dysfunction is another sexual dysfunction; 40% of people with HSSD also had another arousal or orgasmic disorder; multiple causes often the case • Biological causes: DSM sets apart dysfunctions caused by medical conditions by giving them a separate diagnosis; diabetes (reduced circulation), cardiovascular disease, renal failure and spinal cord injury common causes; can be psychological response to presence of disease (ex: fear of heart attack); low levels of androgen and high levels of estrogen/prolactin in men; low levels of estrogen (decrease vasocongestion and lubrication), vaginal dryness/irritation, childbirth injuries in women; genital or urinary tract infections like prostatitis or Peyronie’s disease (fibrous tissue in penis) in men • Drugs: prescription drugs can diminish sexual drive; antihypertensive drugs, antipsychotics, lithium, antidepressants (esp. SSRIs) and tranquilizers; recreational drugs like weed, coke, amphetamines and nicotine can impair functioning and cause substance induced sexual dysfunction • Sleep arousal: if men with erectile disorders have erections during sleep (healthy), than the dysfunction likely has psychological origins; same goes for women experiencing cyclic episodes of vasocongestion in sleep • Psychological causes: loss of sexual functioning common symptom in depression, anxiety disorders and schizophrenia; influence of attitudes and cognitions dealing with dirtiness, shamefulness or sinfulness of sex; may not be knowledgeable about bodies/sexual responses; performance concerns distract from pleasure of stimulation; attend to reactions and performance during sex as if they are onlookers (spectatoring); masturbation in young men is quick, intense and focused on ejaculation which may carry over to partner sex; associate high levels of arousal with anxiety over premature ejaculation which increases chances of it happening • Relationship problems: can be consequences or cases of sexual dysfunctions; conflicts may be about sexual activities or lack of communication (particularly in orgasmic disorders in women) or other problems (suspicion of cheating, lack of trust or respect) • Trauma: reductions in desire and functioning often follow personal traumas; challenge self-esteem and interfered with sexual self-concept; cause experience of depression; sexual assault in women often causes sexual aversion (conditioned generalized aversion of sense of vulnerability and loss of control) • Cross cultural differences: native Chinese and Indian systems teach that loss of semen is detrimental to health and so discourage masturbation; depersonalization syndrome called koro thought to result from semen loss in Asia; less educated and poorer men/women tend to experience more sexual dysfunctions in US • Life span trends: many adults remain sexually active well into old age; testosterone levels begin to decline in 50s for men and continue through life; more difficult to achieve and maintain erections; diminished estrogen in post- menopausal women can lead to vaginal dryness • Pharmacological therapies: treating medical condition or switching/adjusting medication often reduces dysfunction; sildenafil (Viagra)has proven effective in treating men whose erectile dysfunction is caused by antidepressants, medical conditions or has no known organic cause (does not help women); relax muscles that surround small blood vessels in penis, allowing dilation, so blood can flow freely; does not work in 44% of men; yohimbine (African remedy), trazadone (antidepressant) and apomorphine (affects dopamine) have shown modest improvement in helping achieve erections; bupropion (Wellbutrin or Zyban) can reduce sexual side effects of SSRIs and work as an antidepressant; antidepressants can be helpful for premature ejaculation • Biological therapies: hormone replacement therapy effect for men whose low levels of desire are linked to testosterone (mixed and theoretical in women); vaginal lubes help with dryness; can inject smooth muscle relaxants into penis (effective but high attrition); use topical creams with vasoactive properties (uncertain efficacy); vacuum constrictors to create a vacuum when held over the penis (produce erection but not arousal) o Vascular surgery: unblocks blood vessels that supply penis; limited, short term benefit o Semirigid surgical prosthesis: surgical implantation of silicone rods into penis; moderately effective but low partner satisfaction ratings o Inflatable prosthesis: surgical implantation of an inflatable device; highly effective, high patient and partner satisfaction ratings • Psychotherapy: many people seeking treatment only offered a medication (and only want a drug); variety of techniques have been developed • Individual and couples therapy: assess attitudes, beliefs and personal history of client or couple to discover experiences, thoughts and feelings contributing to sexual problems; treat dysfunction in context of relationship; behavioural techniques used to teach skills to enhance sexual experience and prove communication and interactions with partners; focus on marital issues in therapy reduces dysfunction and enhances satisfaction • Seduction rituals: activities that arouse sexual interest in both partners; often abandoned by those in long-standing relationships • Scripts: expectations about what will take place during a sexual encounter and what each partner’s responsibilities are; often differ and resolving these differences may be a useful goal • Direct sex therapy: behavioural techniques used when sexual dysfunction seems to be due in part to inadequate sexual skills of client and partner; learn what practices give pleasure and help develop a regular pattern of sexual encounters; teaching/encouraging clients to masturbate (discover body and become less inhibited; 80% more anorgasmic women can then have an orgasm) and then communicate what they learn to partners; evaluate cognitions that arise • Sensate focus therapy: one partner is active, carrying out of a set of exercises to stimulate the other partner, while the other is the passive recipient, focusing on the pleasure that the exercises bring; then they switch roles; quiet unhurried times; not concerned about intercourse in early phases; partner with the problem instructed to be selfish and focus only on arousing sensations/communication; after regular experience of arousal, partners can begin having intercourse o First stage: gently touch each other but not around genitals; spend intimate time together, communicating, without pressure for intercourse; can continue for several weeks o Second stage: spend time directly
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