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Sexual Disorders. Aaron J. Blashill, M.S. Lykins, Janssen & Graham (2006). Do some individuals with depression and/or anxiety experience sexual arousal as opposed to sexual decline?

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sexual disorders

Sexual Disorders

Aaron J. Blashill, M.S.

lykins janssen graham 2006
Lykins, Janssen & Graham (2006)
  • Do some individuals with depression and/or anxiety experience sexual arousal as opposed to sexual decline?
    • In their review, they found that for both depression and anxiety, there was a subset of individuals who experienced sexual arousal (both men and women).
lykins janssen graham 20061
Lykins, Janssen & Graham (2006)
  • Dual control model
    • Individuals vary in their propensity for both sexual excitation and inhibition
lykins janssen graham 20062
Lykins, Janssen & Graham (2006)
  • Generally, there were subgroups of both men and women who experienced sexual arousal during a negative mood state.
    • Why might some individuals be sexually aroused when distressed?
  • For women, the only variable which research significance in prediction was propensity for sexual excitation accounting for 3% of the variance.
    • Thoughts?
clayton keller mcgarvey 2005
Clayton, Keller & McGarvey (2005)
  • Examining the prevalence of phase-specific SD in a depressed sample without global SD.
  • Comparing prevalence rates of SD for each phase (desire, arousal, orgasm) for men and women.
  • Comparing prevalence rates of phase-specific SD for different SSRI/SNRIs
clayton keller mcgarvey 20051
Clayton, Keller & McGarvey (2005)
  • SD is a common side effect of SSRI/SNRIs
    • Rates from 22-43% to 30-60%
    • What might be some possible effects of deleterious side effects?
  • In their review, authors found that men experienced more impairment in desire than women, but no difference of arousal or orgasm (when on SSRIs and RIMAs)
clayton keller mcgarvey 20052
Clayton, Keller & McGarvey (2005)
  • Evident from clinical practice that phase-specific SD can sig. reduce quality of life even when global SF is not impaired.
  • Results found numerous differences on variables between groups (those with Global SD vs. without)
  • Prevalence rates of phase-specific SD without Global SD: desire (82.4%) arousal (80%) orgasmic (56.6%)
clayton keller mcgarvey 20053
Clayton, Keller & McGarvey (2005)
  • 80% had SD in more than one phase, but still didn’t met criteria for Global SD.
  • Men were sig. more likely to experience SD in the desire and orgasmic phase than women, although vice versa in arousal…Thoughts?
  • No sig. differences between SSRI/SNRIs with regard to phase-specific SD
  • The negative effects on SF appear to be chronic and interfere with the quality of patients life
zucker 2005
Zucker (2005)
  • Gender identity coined in the 1960’s
    • Core gender identity: “fundamental sense of belonging to one sex”
    • Gender dysphoria: extreme unhappiness with ones biological sex
    • Gender Identity Disorder (GID) first appeared in DSM-III
      • 2 diagnoses: Gender Identity Disorder of Childhood and Transsexualism
zucker 20051
Zucker (2005)
  • DSM-III-R Gender Identity Disorder of Adolescence or Adulthood, Nontranssexual Type was added
  • DSM-IV dissolved the above diagnosis and combined GIDC and Transsexualism into one overarching diagnosis, Gender Identity Disorder, with separate criteria sets for children vs. adolescents and adults.
zucker 20052
Zucker (2005)
  • Problems with the criteria set
    • Point A, only need 4 of 5
      • In the absence of criterion AI, perhaps just normal variation in gender expression?
    • Point B, persistent distress
      • Well, what is “persistent”…somewhat vague
      • Some “butch” lesbians has “anatomic dysphoria”…”tranny boys”…not necessarily desire to be the other sex.
zucker 20053
Zucker (2005)
  • Is GID a disorder?
    • Critics of GID has stated that (a) it is nothing more than normal variation in gender-related behavior (b) children with GID show little evidence of distress, and if they do, it is not inherent to the condition, but merely a reaction to social disapproval (c) GID in children is a strong predictor of homosexuality in adulthood, which is a “backdoor” way of preventing homosexuality
zucker 20054
Zucker (2005)
  • Zucker argues that “the distinction between socially induced and ‘in-the-person’ distress may be a false dichotomy”
  • Even if totally accepted by society, there is still distress regarding the incongruity between ones biological sex and gender
zucker 20055
Zucker (2005)
  • Zucker reports case studies relating the comorbidity of PDDs and GID
  • When children with GID are compared to matched clinical controls, levels of behavior problems are comparable
  • Children with GID compared to their siblings and nonreferred children demonstrate significantly more general behavioral problems
zucker 20056
Zucker (2005)
  • Boys with GID are internalizers, whereas girls with GID are not.
  • Children with GID suffer from significant peer difficulties
zucker 20057
Zucker (2005)
  • Links with homosexuality
    • Homosexual men and women report more cross-sex-typed behavior during childhood than their heterosexual counterparts
    • 55 boys with GID
      • At follow-up (ages 13-26) 5 were transsexual (with a homosexual orientation) 21 were homosexual, 1 was heterosexual transvestite, 15 were heterosexual and 13 could not be rated with regard to sexual orientation
zucker 20058
Zucker (2005)
  • Only a minority of children followed prospectively show a persistence of GID into adolescents and young adulthood.
    • Why?
      • A clinical evaluation and subsequent therapeutic interventions during childhood may alter the natural history of GID
      • The diagnostic criteria are not sharp enough to differentiate true GID from normal gender variance
      • The relative malleability of gender in children
zucker 20059
Zucker (2005)
  • The most prominent biological explanation is that both sex-typed behavior in childhood and sexual orientation in adolescents/adulthood are joined together by some common factor or set of factors
    • Example with females with CAH
zucker 200510
Zucker (2005)
  • Other explanations
    • Green (1987): feminine boys’ lack of close relationships with other boys and their fathers might result in “male affect starvation”. In adolescence and adulthood, homoerotic contact is used to achieve closeness with other males
      • Thoughts?
zucker 200511
Zucker (2005)
  • Bem (1996)
    • Atypical gendered children feel different from their same-sex peers, and perceives them as dissimilar, unfamiliar, and exotic. For Bem, this exoticness leads to eroticism…we want what is different and exotic.
      • Thoughts?
blanchard 1989
Blanchard (1989)
  • 2 types of transsexuals
    • Autogynephilics: a male’s propensity to be sexually aroused by the thought of himself as a female
    • Homosexual transsexuals: biological males who wish to be female, and are attracted to men
      • Autogynephilics are biological males, and are attracted to women
        • They also tend to be older, and more masculine than homosexual transsexuals
brotto klein 2007
Brotto & Klein (2007)
  • Sexual dysfunction
    • Problems in desire, arousal, orgasm, or pain
    • Based on Masters and Johnson’s Human Sexual Response Cycle (excitement, plateau, orgasm, and resolution)
      • Desire was added by Kaplan (1979)
    • Problems with this system…
    • DSM-IV divides disorders into 6 categories
brotto klein 20071
Brotto & Klein (2007)
  • Prevalence rates for sexual difficulties in women 43% men 31%
    • Being married and having a higher level of education was associated with lower degrees of difficulties
brotto klein 20072
Brotto & Klein (2007)
  • Hypoactive Sexual Desire Disorder
    • Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity
    • 15% of men aged 19-59 30% of women aged 19-59
    • Hypothyroidism, cancers, cardio-diseases, psychiatric medications, medical drugs, illicit drugs have effects
    • ADAM (andropause…male menopause)
      • Fatigue, depression, reduced sex drive, ED, changes in mood and cognition
brotto klein 20073
Brotto & Klein (2007)
  • Sexual Aversion Disorder
    • Persistent or recurrent extreme aversion to and avoidance of all (or almost all) genital sexual contact with a sexual partner
      • May experience panic attacks
      • Highly distressing (ego-dystonic)
brotto klein 20074
Brotto & Klein (2007)
  • Male Erectile Disorder
    • Persistent or recurrent inability to attain, or to maintain until completion of sexual activity, an adequate erection
      • Causes distress
      • 7% in men aged 18-29, 18% 50-59, 24% 66-74
      • Anxiety or stress may lead to an overactive sympathetic nervous system…leads to loss of erection
      • Major Depressive Disorder strongly associated with ED
brotto klein 20075
Brotto & Klein (2007)
  • Female 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
    • 12-21%
    • Persistent sexual arousal disorder
      • Spontaneous intrusive and unwanted genital arousal in the absence of sexual interest and desire…often only temporarily relieved by orgasm
brotto klein 20076
Brotto & Klein (2007)
  • Female Orgasmic Disorder
    • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase
    • 22-25%...highest prevalence in young women
      • A skill that perhaps develops over time
      • Associated with lower education, high religiosity, and sex guilt…no relationship between rel satisfaction and orgasmic ability
    • Myth of the “G-spot”?
brotto klein 20077
Brotto & Klein (2007)
  • Male Orgasmic Disorder (retarded ejaculation)
    • Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity
    • Much less frequent than PE (premature ejaculation)
    • 8% men aged 19-59
    • Idiosyncratic masturbatory style, variant sexual fantasy, predisposing factors…alcohol use related and performance anxiety
brotto klein 20078
Brotto & Klein (2007)
  • Premature Ejaculation
    • Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it
    • 30% of men aged 18-59
    • Most prevalent male sexual dysfunction
    • Highly embarrassing condition
    • Serotonergic disruption likely primary etiological factor
    • 71% of first-degree relatives of men with PE also have the condition
    • situational/acquired PE may be more due to anxiety, early sexual experiences, low frequency of sex, or poor ejaculatory control techniques…new studies suggest that anxiety is more of a consequence rather than a cause
brotto klein 20079
Brotto & Klein (2007)
  • Dyspareunia
    • Recurrent or persistent genital pain associated with sexual intercourse
    • 3-5% men in Western cultures 10-12% in Middle East and Southeast Asia…14% in gay men (anodyspareunia)…most experiencing it lifelong
    • Psychological factors play a primary role in the etiology in men
    • In women, psychological factors are considered secondary, but can exacerbate pain (anxiety, depression, self-esteem, harm avoidance, somatization, shyness, and pain catastrophization)
brotto klein 200710
Brotto & Klein (2007)
  • Vaginismus
    • An unwanted involuntary spasm of the vaginal muscles that prevents intercourse
    • Often a phobic avoidance and anticipation or fear of pain
    • 1-6% of women
    • Highly comorbid with dyspareunia
    • Behavioral theory views it as a conditioned reaction during a single sexual encounter (sexual assault) or over reapted trials (having sex with dyspareunia)
    • Physiological view considers it a pelvic floor dysfunction
    • Interactional view suggests it maintains balance between partners
      • Male partners are passive, dependent, anxious, and lacking in self-confidence, who often suffer from their own SD, therefore vaginismus maintains a balance in a sexless relationship
    • Multidimensional view looks at many factors
brotto klein 200711
Brotto & Klein (2007)
  • Paraphillas
    • Recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects, activities, or situations and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
brotto klein 200712
Brotto & Klein (2007)
  • Exhibitionism
    • Recurrent and intense sexually arousing fantasies, sexual urges, or behaviors of exposing ones genitals to an unsuspecting stranger over a period of at least 6 months
    • Most commonly reported paraphilia
    • Victims usually women, including children
    • It’s the victims shock that is sexually arousing to the perpetrator
    • Don’t appear to differ from the general population on various traits
brotto klein 200713
Brotto & Klein (2007)
  • Fetishism
    • Recurrent sexual arousal toward nonliving objects that are present for at least 6 months and accompanied by impairment
    • Largely a disorder of men
    • Pretty much any object you can think of can be an object of fetish
brotto klein 200714
Brotto & Klein (2007)
  • Frotteurism
    • Sexual arousal involving touching and rubbing against nonconsenting individuals
    • Distress and impairment not necessary if the individual acted on it (similar to exhibitionism in this regard)
    • Generally takes place in crowded places
    • Typically fantasizes about having a sig. relationship with victim
    • Mainly occurs in men
brotto klein 200715
Brotto & Klein (2007)
  • Pedophilia
    • Sexual arousal toward a prepubescent child, over the course of 6 months, must have experienced distress, or have acted on the urges
    • Must be at least 16, and at least 5 years older than the prepubescent target of arousal
    • Child molesters do not suffer from higher rates of psychopathology than non-molesters, although about 50% experienced sexual abuse as a child
    • May lack empathy towards their victims, but not in general
    • Originally viewed to be only a disorder of men, data now emerging on females
brotto klein 200716
Brotto & Klein (2007)
  • Sexual Masochism
    • Sexual arousal in response to being humiliated, bound, or beaten, for at least 6 months and suffer impairment, the arousal must be in response to actual, not simulated humiliation, bondage, or beatings
    • Most sexual masochists use little or no pain, more so through the loss of control
    • Can lead to serious injury and death (especially in the case of hypoxyphilia)
    • 20:1 males: females
    • Appears to be modern compared to other paraphilias, as well as limited to Western cultures
    • More common with individual with higher income
    • No relationship between sexual masochism and non-sexual forms of masochism
    • Tend to be well-adjusted, and often quite successful, and above norms on measures of mental health
brotto klein 200717
Brotto & Klein (2007)
  • Sexual Sadism
    • Recurrent sexual arousal over 6 months in response to fantasies, urges, or behaviors involving the psychological or physical suffering of another, these must have been carried out, must be distressing, or cause interpersonal difficulty
    • Can lead to serious injury of death (specifically when there is comorbid ASPD)
    • More common in men than women
brotto klein 200718
Brotto & Klein (2007)
  • Transvestic Fetishism
    • Specific to heterosexual men, 6 months of recurrent sexual arousal associated with wearing women’s clothing and accompanied by sig. distress
    • May experience gender dysphoria, although many are happy with their gender and only cross-dress in sexual situations
    • Tend to be relatively masculine
brotto klein 200719
Brotto & Klein (2007)
  • Voyeurism
    • Recurrent, intense sexual arousal of seeing unsuspecting people naked, in the process of undressing, or engaging in sexual activity
    • Must have acted on the urges, or has caused impairment
    • Tend to have deficits in social and assertiveness skills as well as sexual knowledge
brotto klein 200720
Brotto & Klein (2007)
  • Theories
    • All lacking in data, however, provides some theoretical explanations
    • Neurological deficits
      • Neurological abnormalities in the temporal lobe and limbic area
      • Although, many studies have found temporal lobe disorders are associated with hyposexuality, as opposed to hypersexuality
brotto klein 200721
Brotto & Klein (2007)
  • Social
    • Childhood abuse
      • Doesn’t account for the many individuals who suffered child abuse and did not go on to develop paraphilias
    • Cognitive-Behavioral
      • Operant and classical conditioning
        • Sexual arousal can be conditioned, however, extinction occurs easily
      • Role of cognitions
        • Minimization and denial of harm, which disinhibits individuals to act on their initial paraphilic interests and then serves to maintain them