1
Q
What is a sexual problem?
A
A sexual difficulty that the person identifies as a problem that causes them distress
(some people have low desire but not distress which is not a problem).
Categorized as problems with: desire, arousal, orgasm, sexual pain
2
Q
What has happened to the DSM focus since Kaplin?
A
now that desire is added the DSM has expanded
3
Q
What happened to the diagnosis of hypoactive sexual desire disorder in the DSM 5?
A
Now it is only for men; women has changed to sexual interest/arousal disorder
4
Q
Why was sexual aversion disorder removed?
A
It can be explained better by other disorders
5
Q
What happened to the diagnosis of dyspareunia?
A
in men its nothing and in women its genito-pelvic pain/penetration disorder
6
Q
What 2 things are required for all clinical diagnoses?
A
the problem must occur for 6 months and it must cause distress/interpersonal difficulty
7
Q
What is sensate focus therapy?
A
requires couple to redirect emphasis away from intercourse and focus on their capacity for mutual sensuality. Will often avoid sex and intimacy all together.
o No sex can happen the session.
o Take turns touching each other and say what you like/dislike
o Takes the pressure off of performance
8
Q
Directed Masturbation
A
therapist provides instructions on how to use masturbation to overcome a specific problem.
o Just focussing on the sensations without the goal of having an orgasm.
9
Q
Cognitive Behavioral Therapy
A
addressing problematic/incorrect thoughts and behaviors together
10
Q
What is the fourth type of common sex therapy?
A
Learning verbal communication skills
11
Q
What is touch mirroring ? Why is it a problem?
A
a problem with nonverbal
>If you want someone to touch you more gently you might start trying to touch your partner more gently, but that might not be what your partner wants. So then nobody is getting what they want.
12
Q
What is new to the DSM?
A
Factors Related to Sexual Problems
- New to the DSM because of the new view of women’s problems
- Now for all disorders listed in the DSM, clinicians have to say if the problem is related to any of the 5 factors
13
Q
What are Intrapsychic Factors?
A
- Pretty much everything
- Family messages about sex (not talking about it can even be a strong message)
- Lead to our views and values about sex
- Sexual experiences/abuse
- Self-esteem (if you don’t feel worthy of pleasure)
- Fear of consequences (STI, pregnancy, being called a slut)
- Stress/anxiety
- Guilt (if you received messages that sex is dirty and bad, often stems from religion)
- PTSD
- Cultural expectations that everyone should be sexually active and skilful and find sex easy and effortless create the foundation for performance anxiety
14
Q
What are Intrapersonal/Relationship Factors
A
- Changes in sexual response are often related to relationship factors
- Poor communication (most common problem in therapy)
- Usually bad at conflict resolution (learned from observation during childhood)
- Which may result in anger and resentment
o because when one cannot express anger they will eventually be unable to express or experience passion
o Think about a couple fighting about how often, when and who should initiate sex? While it might be a fight about sex, sex might actually be a stand in - Conflicting sexual expectations
o We know what we want out of the relationship/sex and we expect that the other person feels the same, or we think they know what we want (can be frequency, type of sex, etc.) - Lack of trust
o Gut feelings/lack of trust/don’t feel safe can lead your body to shut down in that way - Lack of respect
- Fear of hurt or disappointment (fear of being betrayed again)
15
Q
What are cultural/psychosocial factors?
A
- Huge, often invisible factors
o Because if you are born into it you don’t realize what you’re in without being aware, because we’re unaware of what we don’t know it can lead to conflicts in relationships - Ethnic background
- Religious background
o Which now Is incredibly different all across Canada due to the decline of protestant and roman catholic teaching and now there are less adults who identify as Christians, as well as numerous denominations popping up - Family
o When parents try to get their kids to not “touch themselves” - Social background/social circle
o Ex: if you were the only gay guy in your social circle and hid that/pushed it down for years can be harmful in the future - School education
o Mostly focused around consequences, nothing about healthy relationships
o In Canada its biology, avoiding STIs and not much about sexual feelings, desires or pleasures - Media (mainstream, social, porn)
o Reinforce unrealistic body images and performance expectations - Tiefer – Cultural variations in kissing behavior
o A couple, the woman’s Asian culture did not sexualize kissing and she found it repulsive. His culture thought it was passionate. - What is “normal” in one culture may not be in another
16
Q
T or F? - “real” sex equals intercourse
A
False
17
Q
T or F? Sexual satisfaction equals orgasm
A
False
18
Q
T or F? - Bigger isn’t better (when it comes to breasts and penises)
A
True
19
Q
T or F? - Sex goes downhill after marriage; it gets even worse when you have children. If that’s what you believe that’s probably what you’ll make happen
A
False
20
Q
T or F? - A man always wants and is ready to have sex
A
False
21
Q
What are 5 organic factors linked to sexual problems?
A
Neurological, Hormonal, Vascular, Recreational drug use, Prescription drug use
22
Q
How can neurological damage affect someone’s sexual functioning?
A
o Any damage/problems to brain and spinal cords (MS) can affect the nerves connected to skin and gentiles
23
Q
In terms of neurological factors, what can diabetes lead to?
A
peripheral neuropathy: which can affect sexual functioning by reducing blood flow to the genitals and eventually cause deterioration of nerve functioning (pain, weakness or numbness of nerve outside the CNS)
24
Q
What are 2 hormonal factors?
A
o Hypothyroidism (low thyroid hormone levels) o Anemia (decreased in RBC due to iron deficiency)
25
What are 2 vascular issues that could affect blood flow and therefore genital arousal?
o Diabetes, cardiovascular disease
26
Recreational drug use includes alcohol and smoking. How does each affect sexual functioning?
Alcohol
♣ Reduce inhibition, but increase desire
♣ Reduces blood flow, lubrication
♣ So more desire, but less physiological response
Smoking
♣ Reduced blood flow
♣ Weed has been advocated to enhance sexuality
27
What types of prescription drug use can cause sexual dysfunctioning?
Anything affecting blood flow Antidepressants tend to delay orgasms
28
What is an aphrodisiac?
a substance alleged to induce sexual desire (there isn’t any true ones)
29
What is inadequate sex?
Meaning the sex, they are having is not the best for them. They are not having the sex they want to have.
30
What does quality sex require?
People to have enough self-knowledge about their desires and be able to discuss their needs and desires.
31
Masters and Johnsons had 5 points of criticism for their model; what were all 5 and explain.
1. Developed the model before doing the research. So they sought people out who fit their premeditated model
2. Assumption that physiology is universal . Called it “the human response cycle” not “a human response cycle”
3. What is “effective sexual stimulation”?Never actually define what it is
4. Participant selection bias – wanted to show that women were sexual too. Identical performance requirements for males and females. Not a representative class sample
5. Participants trained on “responding” to various stimuli in the laboratory. “When female orgasmic or male ejaculatory failures develop in the laboratory, the situation is discussed immediately. Once the individual has been reassured, suggestions are made for improvement in future performance. Therefore, only concerned with people who responded the way they wanted people to respond and would coach them if not.
32
What classification system did the New View adopt instead of Masters and Johnsons model?
A biopsycho-social model. Not to say M&J model was not important but it was constrained to the physiological response.
33
Why did the New View lobby for change in the classification of sexual problems in the DSM? What did the new view argue?
The DSM only wanted to talk about disorders in the context of what the cause was
o The New View argued the cause of the sexual problems was what we needed to know to fix it rather than just focussing on the fact the the individual is not orgasming
34
What were the 4 new view classifications?
o Sexual problems resulting from sociocultural, political, or economic factors
o Sexual problems relating to partner and relationship
o Sexual problems resulting from psychological factors
o Sexual problems resulting from medical factors
35
Medicalization of sexuality affects who?
Men and Women
| EVERYONE
36
Who medicalized 'impotence' with Viagra?
Klein and Morin
37
What was viagra originally intended for?
people with circulation problems and diabetes.
38
What is the caveat with Viagra?
o Viagra works 80% of them time for performance anxiety – (not working on feelings thought, just pop a pill)
o Viagra only 65% effective for men with actual organic problem
Caveat: It essentially works better on people with no organic disorder/problem
39
What is Male Hypoactive Sexual Desire Disorder (MHSDD)?
Low desire for sexual activities and absence of sexual thoughts and fantasies
40
Sexual Interest/Arousal Disorder. What gender is it limited to? What is it? When is this disorder almost never seen STACY?!
In women only.
It is inhibited desire/interest for sexual activity and/or inhibited psychological arousal.
Almost never seen in Pre-menopausal women, almost none actually had no problem with genital arousal
- Post-menopausal, it’s a completely different problem because there are physiological effects
41
What is the most pervasive and difficult sexual problem to treat?
Low desire
42
What 'dysfunction' isn't really a thing that has been rejected and has no formal diagnosis?
high desire = sex addiction
43
What is treatment for life long low sexual desire?
o Screen for endocrine disorders, illness, medication use, depression
o Treat for underlying medical problem if there is one
o Testosterone and other androgens
44
If not a medical issue, what is 6 treatments for low sexual desire
Talk therapy to understand root causes
o Stress – stress hormones can supress testosterone
o Exhaustion – hard to have desire when you’re exhausted
o Relationship problems – could be arguments, not feeling supported, type of sex
Sensate focus
Directed masturbation
Cognitive Behavioral Therapy
Erotic material
Flibanserin (Addyi) – Pharmacological treatment for women
o Originally intended to be an antidepressant
o Reported having more desire for sex
o Causes severe low BP and fainting in people who drink alcohol
45
What is Erectile Dysfunction?
Persistent or recurrent inability to attain or maintain erection until completion of the sexual activity with an adequate erection (more about maintaining than attaining). Highest in men over 50; because as you age blood flow decreases.
46
What are physiological factors of ED?
- Anything interfering with blood flow or tactile stimulation
- Cardiovascular disease, diabetes, side effects of medications
47
What are psychological factors of ED? (5)
- Relationship problems
- Chronic stress
- Previous sexual abuse
- Sexual myths: men are always ready and willing to have sex
- Anxiety
48
Where does the anxiety associated with ED stem from? (5)
-Performance pressure
-Fear of failure
-Distraction:
♣ When anxious you go into the fight or flight mode; you might be thinking about how worried you are about work and not focussing on the sexual cues.
-Anxiety disorder
-Masters and Johnson’s “Spectatoring” :
♣ Instead of being present during the moment of sexual activity; you’re thinking about what you’re doing. Being s spectator of the sexual activity instead of participating in it.
• “am I touching them right, etc.”
49
Describe the sugar pill study and how anxiety was shown to have the opposite effect on arousal in men without the dysfunction than in men with it.
Told it was a sugar pill
♣ Without sexual problem: aroused no problem
♣ With sexual problem: got just as aroused, just took them longer
Told it was an anti-erection pill (anxiety stimulus) but told to try their best to get one
♣ Without problem got even more aroused
♣ With problem: had much lower arousal
Put that performance anxiety on them and interfered with their ability to get aroused
50
What is Barlow's Model of Sexual Dysfunction? (5 phases)
If they have a history of low performance.... Phase 1:
o Go into the negative feedback loop
o So focussed of not getting an erection that they underreport their erection
Phase 2:
o Focus more on not performing
o Might go into spectatoring
Phase 3
o Increased autonomic arousal: higher heart rate and blood flow
o But happening because they are nervous not turned on
Phase 4:
o The active autonomic system allows you to hyper focus in this case on not being hard
Phase 5:
o Erectile dysfunction
Obvious how this can lower desire cognitively if every time you have sex it’s a bunch of anxiety
51
What is the first step in treatment of ED?
Determine if the cause is psychological or physiological
52
How do you determine if ED is psychological or physiological
Monitor nocturnal penile tumescence (swelling)
| ♣ Had men wrap a role of stamp around their penis and see if its broken in the morning due to swelling during REM sleep
53
What are 3 psychological treatments for ED?
```
Anything to so with mindfulness....
Sensate focus
Cognitive behavioral therapy
♣ A huge part is our cognitive beliefs
♣ Feels like automatic thoughts
Need to catch, stop and reframe
Relationship therapy
```
54
What is the pharmaceutical fix to ED?
Phosphdiesterase type-5 (PDE5) inhibitors: Sildenafil (Viagra), Tafalafil (Cialis); Vardenafil (Levitra)
55
How does viagra work?
It affects the nitric oxide system...
♣ PDE5 enzyme breaks down cGMP
♣ cGMP is part of the chain responsible for relation of smooth muscles (needed for erection)
♣ PDE5 inhibitors prevent PDE5 from doing its job, to essentially just make the erection last longer. PDE5 inhibits the inhibitors. Helps the arteries of the corpora cavernosa to dilate more readily and stay that way
56
What does Viagra not do?
make the person aroused or hard if not sexually stimulated. ♣ Which may be why many Viagra prescriptions are not refilled because they are not a quick fix; they do not give you an erection without thinking about it. You still need stimulation in the way that turns you on.
57
What is the most successful combo of treatments for ED?
a combination of sex therapy and PDE-5 than just PDE-5 alone
58
What are 6 physiological factors of arousal disorders?
- Disease
- Medications
- Drugs/Alcohol
- Smoking (nicotine inhibits arousal)
- Hormones (testosterone/estrogen/prolactin)
- Cardiovascular problem (anything that prevents blood from flowing)
59
What are 6 psychological and relationship factors of arousal disorders?
-Is the person psychologically aroused?
-Is sex pleasurable?
-Fear of consequences
-Guilt
-Relationship issues
o Conflict
o Anger
o Lack of attraction
-Anxiety, stress
60
Lack of lubrication is almost...
non-existent in pre-menopausal women
61
What are some physiological causes of lack of lubrication?
Review physical causes (estrogen deficiency, vascular disorder, diabetes, lactin increase due to breastfeeding)
62
What is Eros-CTD
a clitoral therapy device used for treatment of lack of genital arousal.
63
What is FOD?
Female Orgasmic Disorder (FOD)
| - Persistent inability to reach orgasm after appropriate stimulation
64
What is the only physiological caused for FOD?
nerve damage = no orgasm
65
What are the 4 causes of primary FOD (never O'd in your life)?
o Lack of education (on what would lead to an O)
o Lack of stimulation (genitally and psychologically)
o Guilt
o Embarrassment (noises, faces, movements)
66
What are 5 secondary causes for FOD (Have O'd before)
```
o Alcohol & drugs
o Medications
o Psychological factors
o Relationship factors
o Nerve damage
```
67
Is primary or secondary FOD harder to treat?
Secondary because more complex
68
What are 4 treatments for FOD?
- Masturbation
- Education (bibliotherapy)
- Sensate focus (in the moment it deprioritizes an orgasm)
- Change medications
69
What is pre-mature ejaculation?
Persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it
70
What is the 4 criteria for PE?
- 60 second intra-vaginal ejaculatory latency (IELT), 75% of the time for at least 6 months and distress
71
What factors must we take into account for PE?
o Age: younger is quicker
o Novelty of sexual partner or situation
o Frequency of sexual activity
72
What are 6 causes of PE?
- Sensitivity
- Goal-focused masturbation/rushed masturbation (trying to get off before mom opens the door)
- Lack of awareness of sensation before ejaculation
- Infrequent sexual activity
- Heredity
- Unrealistic expectations of himself
73
What are 3 home remedies for the treatment of PE?
o Wearing 2 condoms
o Ordering “stay hard cream” on the internet which are topical anesthetics
o Recall a bad thought
74
What should you consider before seeking treatment for PE?
- is it necessary? is your partner okay with how quick you are?
- Identify cause of distress (is it because you think your partner will be upset, you’re not living up to a standard you have for yourself?)
75
What are 2 drugs to use for PE?
```
o Antidepressants (SSRIs delay orgasms)
o Topical anesthetics (Not recommended)
```
76
What is a behavioural technique for the treatment of PE?
Stop-start technique
♣ Masturbation/oral sex to teach the point of ejaculatory inevitability, not to ejaculate, called “edging” if doing it for fun
77
What does Ian Kerner outline in his book about orgasms
o Says you just need to have sex differently
| o If your partner has already gotten off, then there is less pressure for the male
78
What is delayed ejaculation?
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase
79
Anorgasmia
persistent inability to have an orgasm
80
What is DE usually restricted to?
inability to reach orgasm in the vagina, not alone
81
What are 7 potential causes of DE even thought it is not well known?
- Heredity
- Medications (SSRIs and SNRIs)
- Alcohol
- Fear, guilt (risk of getting someone pregnant)
- Relationship issues (thinking a hard on means he wants to have sex)
- Masturbation techniques (idiosyncratic style)
- Porn?
82
What are 3 treatments for DE?
- Changing medications
- Varying masturbation routines
- Therapy related to relationship or other psychological issues
83
Dyspareunia
pain during intercourse or pain related sex. Could be caused by STIs, tumors of the prostate. Generally focused on treating the disease.
84
What is penetration-related pain possibly related to? when is it most commonly experienced? when can it occur? what can it feel like?
- Possibly related to lack of lubrication
- Most commonly experienced during PVI
- May also occur before or after intercourse
- Pain deep in pelvis or itching/burning of the vagina
85
What are 4 causes of penetration pain?
- Endometriosis, scarring, unusual skin sensitivity, genital infections, tumors, heightened inflammatory sensitivity, allergic reactions, etc.
- Vaginal dryness
- Following menopause, atrophy of the vulva and vaginal tissue
- Psychological factors
86
What is treatment for GPPPD for women?
Lube & estrogen creams
87
What is treatment for GPPPD for men and women?
- Address any underlying infections
- Psychological approaches
- If related to global pain sensitivity – numbing agents
- May be untreatable
88
What is the muscular component of GPPPD?
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
- Desire, arousal, orgasm may not be impaired unless penetration attempted or anticipated
- The physical obstruction due to muscle contraction usually prevents intercourse
- Not restricted to sexual penetration
89
What is often linked to the muscular component of GPPPD?
fear of penetration of fear of pain
90
What are some treatments for vaginismus?
- Graduated dilated couples with relaxation
- Identify faulty beliefs
- Educating women and partner about normal sexual anatomy and physiology
- Sensate focus
- Estimates suggest 60-100% of vaginismus cases successfully treated with behavioral/psychological intervention
- Botox injections being used off label (extreme)
91
Historically, who treated sexual difficulties?
Historically, treatment was left to the clergymen, general psychotherapists or marriage counselors
92
What changed?
Masters and Johnsons when they released their book sexual inadequacy and created a new field of sex therapy
Human Sexuality
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