HC 4 Sexual Dysfunction in female 

What do women mean when they say that they are 'sexually aroused'?

• Are they saying that they want to have sex?
• Are they saying that their present situation is sexually appealing to them?
• Are they describing what is happening in their body's?

Sexual response cycle (DSM IV): Desire --> arousal --> plateau --> orgasm --> recovery

Sexual disorders in women according to DSM IV 

• Sexual Desire Disorders 
  • Hypoactive sexual desire
  • Sexual aversion
• Sexual arousal disorders
  
  • Lubrication problem
  • (PGAD)
• Orgasmic disorders
  
  • Anorgasmia
• Sexual pain disorders
  
  • Dyspareunia (pain during intercourse)
  • Vaginismus (not being able to have intercourse at all)

Sexual disorders in women according to DSM V 

• Sexual Interest/Arousal Disorder
• Orgasmic Disorder
• Genito-Pelvic Pain/Penetration Disorder
  
  • Dyspareunia
  • Vaginismus 
• Unspecified Sexual Dysfunction
  
  • Sexual Aversion

All these problems should cause significant suffering/distress or relational problems/ should not better be explained by other mental disorders or only consequence of a somatic illness.

All these problems can be..

• Lifelong: it has been present since the person became sexually active
• Acquired: it began after a period of relatively normal sexual function
• Generalized: in all types of stimulation, partners, situations 
• Situational: only with certain stimulation, partners and situations

Hyposexuality: persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. 

• Incentive-motivation model: sexual desire results from confrontations with sexual stimuli or from thoughts of sexual stimuli 

• Person: push factors --> transmitters/hormones 
• Situation: pull factors --> presence/absence of stimuli 

Sexual motivation model --> see the model on Blackboard 

Arousal and desire are to sides of the same coin.  

In DSM V --> Female sexual interest/ arousal disorder

An instrument to measure arousal: vaginal photoplethysmograph (measures lubrication)

Results research: They found no difference in objective arousal (lubrication and swelling of genital area) between women who report arousal problems and the control group of women without sexual problems. However, women with an arousal problem say that they experience less subjective arousal in the lab than women without arousal problems. They don't experience arousal in the head. 

Sexual interest/arousal disorder (DSMV)

Min 3 van de 6:

1. Absent / diminished interest in sexual activity 
2. Absent / diminished sexual thoughts or fantasies 
3. Absent / diminished initiation of sexual activity and responsiveness to partner’s attempts to initiate 
4. Absent / diminished sexual excitement / pleasure during sexual activity 
5. Absent / diminished sexual interest / arousal elicited by internal or external erotic cues 
6. Absent / diminished sensations during sexual activity

• >6 months
• Distress
• Not due to another disorder (Axis I disorder) --> VB depression 
• Or severe relationship problems (violence) 

Bancroft sexual excitation-inhibition model/dual control model: 2 basic processes underlie human sexual response: Inhibition and Excitation (= responding with arousal to sexual stimuli). Women --> more inhibition 

Etiology of interest/arousal problems

• Relational aspects: less satisfied with the relationship in general 
• Psychological aspects: mood, negative body perception, chronic stress, depression 
• (psycho)somatic aspects: thyroid disorders, chronic disease (dialysis for kidney diseases), drugs such as long-term use of Prednisone, premature menopause due to gynaecological cancer, fertility problems   

A critical view of female dysfunctions (Tiefer)

1. sexual problems due to sociocultural, political or economic factors
2. sexual problems related to partner and relationship
3. sexual problems due to psychological factors 

 Treatment interventions for interest/arousal 

• Focus on the PR and context: what is going on, what are they doing? Sometimes the problem is with the relationship
• Sensate focus exercises: focus on what you feel. Vb: start stroking/feeling
• Look for appropriate and new sexual stimuli:
• Fantasies/reading erotic literature
• Masturbation 
• Cognitive therapy (Rational Self-Analysis) 

Before: Sexual aversion/disgust (DSM IV)  --> Now: Not otherwise specified disorder (DSM V)

Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.

Arousal and desire: No tendency towards sexual action and no experience of arousal or desire but instead escape of avoidance 

Etiology (primary)

• More often negative sexual experiences 
• More orthodox religious upbringing 
• Negative messages about sex in childhood (is bad /disgusting) 
• Few known somatic factors

Treatment: Focus on potential trauma's (EMDR), then further sex therapy (CBT) 

Female orgasmic disorder (DSM V)

Persistent or recurrent delay in, or absence of orgasm; significantly reduced intensity of orgasmic sensations   

To get an orgasm, the female should focus on themselves, be fully aware of what you are feeling. People close their eyes, is naturally. The body and psychology work very well together. 

Etiology

• Psychological factors: limited autonomy, lack of assertiveness, fear of loss of control, negative attitudes towards sex. Insufficient stimulation (often lifelong) 
• Somatic factors: deterioration of central nervous system/spinal cord/peripheral nervous system (MS, operations, side-effects of specific SSRI drugs, anti-psychotics) 
• Acquired/situational: cause often related to context, diminished sensitivity due to ageing

Ingredients of orgasm training (lifelong/secondary)

• Psycho-education about arousal 
• Looking for sexual stimuli 
• Exploring your own body and genitals (sensate focus) 
• Masturbation exercises --> best treatment for orgasm training
• Using a vibrator --> strong stimulus and quick; for example, when people are afraid of losing control 
• Exercises for relinquishing control (imagination) 
• Role play of orgasm --> acting out the idea women have of an orgasm

Sexual pain disorders (DSM IV-TR)

Dyspareunia: recurrent or persistent pain associated with sexual intercourse

Vaginismus: recurrent or persistent spasm of the pelvic floor muscles that interferes with sexual intercourse (Sexologist do not agree with this explanation)

• Vulvodynia: chronic vulvar pain 
• Vaginismus: intercourse impossible
• Dyspareunia: painful intercourse  

Today: genito-pelvic/ penetration disorder (DSM V)

They fused dyspareunia and vaginismus together --> Sexologists do not agree, they say that these are different disorders

1. Persistent or recurrent difficulties with at least one of the following:

1. Vaginal penetration / intercourse 
2. Vaginal or pelvic pain during penetration or attempt at penetration 
3. Fear or anxiety about pain in anticipation of or during vaginal penetration 
4. Tightening or tensing of the pelvic floor muscles during attempted penetration 

 Dyspareunia, pain 

• Inserting, during and after penetration 
• Penetration of penis, tampons, fingers 
• Pain during cycling and wearing tight clothes, 
• Burning, aching sensation 
• 75 % dyspareunia ~ PVD/VVS

Etiology

• Organic factors: recurrent infections, early contraceptive use, genetic susceptibility to inflammatory disorders 
• Pelvic floor muscle problems 
• Psychosocial factors: Cognitive styles, personality traits, sexual abuse history relationship factors, sexual function 

Psychosexual assessment

• Pain: location, quality, onset, duration, elicitors, intensity, what hurts (finger, tampon) 
• Cognitive-Behavioural factors (model) 
• Impact on sexual functioning (general) 
• Partner and relationship factors (model) 
• Co-morbid pelvic floor complaints: Bladder routine (frequency, control); Bowel routine (constipation) 
• Earlier treatments/ 
• Request for help

 Treatment for PVD/VVS: physiotherapy 

• Exercise therapy + EMG bio-feedback 
• Exercise therapy using verbal instructions 

CBT treatment in contra-indications 

• Severe psychopathology (depression)
• Severe relationship problems 
• PTSD symptoms * touch
• Essential vulvodynia (chronic pain)

Summary 

• During the anamnesis, make sure that all potential BPS factors have been addressed before reaching a DSM diagnosis of the complaint 
• For women, the situational context and the relationship are very important in the experience of sexuality 
• In practice, time will tell what consequences the changes in the DSM V will have for the clinical situation and in the area of research

HC 5 Sexual Dysfunctions in male

There have been some changes in criteria from DSM IV to DSM V --> zie bb

Criteria for diagnosing a sexual dysfunction in DSM 5 

• Must cause significant distress
• Must occur on 75%-100% of occasions
• Minimum duration of 6 months 
• Not attributable to
  
  • Another disorder (Axis 1 disorder)
  • Severe relationship distress
  • The effects of medication/substance (e.g. Alcohol/drugs)

 Subtypes

• Lifelong vs acquired
• Generalizes vs situational
• Severity (mild/ moderate/ severe) 

Sexual dysfunctions in men 

• Male hypoactive sexual desire disorder
• Erectile disorder
• Delayed ejaculation 
• Premature (early) ejaculation
• Other specified sexual dysfunctions
  
  • Genital pain
  • Sexual aversion
  • Hyperactive sexual desire (hypersexuality)
• Body dysmorphic disorder
• Unspecified sexual dysfunctions

 Substance/Medications-Induces Sexual Dysfunctions

• Disturbance of sexual function
• Evidence from the history, physical examination or laboratory findings
• Developed during or soon after ingestion of substance/ medication or withdrawal
• The substance/medication is capable of producing sexual problems as a side effect 
• The disturbance is not better explained by another sexual dysfunction 
  
  • E.g. because the symptoms persist after cessation of the substance/medication   

Male Hypoactive Sexual Desire Disorder 

Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The assessment of this must take account of factors such as age and lifestyle. A problem for a 25-year old can be normal for an 80-year old. 

Prevalence 

• Periodically: 0-6% (18-24 years) and 41% (66-74 years)
• Longer than 6 months: 1.8% (16-44 years)  

A sexual response requires

• Adequate sexual stimulus
• Genital response, subjective experience of arousal
• Situational factors (context, opportunities, motivation)
• Physiological sensitivity (androgenic, hormones, neurotransmitters, etc.) 

Role/production of testosterone

Production in the Leydig cells of the testes and the adrenal glands. Production is regulated from the pituitary gland by LH (luteinizing hormone) and FSH (follicle stimulation hormone).  

A minimum of testosterone is needed in order to function sexually. Testosterone makes the system ready for sexual activity. Lower levels are found in 1% of men aged between 20 and 40 but in 20% of over-65s. Very low amounts of testosterone are very rare (1%). A high amount of testosterone does not mean you want to have a lot of sex. 

Reasons for low levels of testosterone (Hypogonadism)

• Disturbance in testosterone regulation from the hypothalamus 
• Congenital functional disorders affecting the testicles 
  
  • For example Klinefelter's Syndrome 
• Prolactinoma (benign tumour in the pituitary gland) 
• "Late-onset" hypogonadism (metabolic syndrome)
  
  • Obesity (increased waist circumference): “belly fat” 
  • Raised blood pressure /cholesterol
  • Raised blood sugars (type II diabetes) 

Sexual desire and psychiatric problems 

• Depression >40% reduced desire, but 9% increased desire 
• Difficult to distinguish from the effect of medication 
• The same for drug abuse 

Sexual Motivation 

Diagnosing 

• Physical examination and lab tests
• Individual's history (anamnesis), focusing on
  
  • Asking about psychiatric co-morbidity
  • Negative sexual experiences
  • Interest in sexual stimuli
  • Relational factors
  • "lifestyle" (alcohol and drugs)
  • What is the situation regarding "sexual motivation"?

Treatment

• Testosterone supplements --> can help by giving a kickstart but doesn't help in itself
• Sexual counselling
• Combination 

Testosterone supplements in men with androgen insufficiency

Improvement in:

• Number of sexual fantasies 
• Sexual arousal and desire 
• Spontaneous nocturnal and morning erections 
• Sexual activity (masturbation and with a partner) 
• Number of orgasms 

Sexual counselling 

• Lifestyle changes: Loss of weight and exercise 
• Break the pattern of avoidance behaviour 
  
  • Look for sexual cues (e.g. porn) 
  • “Sensate focus” couple exercises: focus on sexual responses and 
    erogenous zones 
• Cognitive restructuring (Rational Emotive Therapy) 
• Couple therapy: for example, communication exercises, communicate what you like sexually 

Erectile Disorder (ED) 

Criteria

• Marked difficulty in obtaining an erection during sexual activity 
• Marked difficulty in maintaining an erection
• Marked decrease in rigidity 

Prevalence 

• 13% - 21% aged 40-80 years 
• 2% of men younger than 40 years 
• 40-50% older than 60-70 years 
• 8% of men experienced ED during the first attempt at coitus 
• 20% fear that this might occur 

Biological, medical and lifestyle "risk" factors 

• Trauma
• Pelvic surgery
• Neurological diseases
• Hormonal diseases
• Alcohol, drugs use
• Age 
• Cardiovascular diseases 
• Hyperlipidemia
• Diabetes mellitus
• Side effect of medication 
• Smoking  

Social and relational factors in ED

• "erotophobia": learned negative sexual attitudes towards sexuality
• Poor interpersonal relationships, lack of communication 

Psychological factors

• Temporary “normal” episode related to a period of stress 
• Psychopathology (NB depression) 
• Negative cognitive schemas (due to (general) negative or traumatic sexual experiences) 
• Fear of failure (“performance anxiety”) 

Psychophysiological research on fear of failure, performance pressure and sexual arousal 

• Negative affect in relation to sexuality 
• Underreporting of the level of sexual arousal 
• Reduced perception of control in relation to sexual arousal 
• Distracted by performance-related stimuli 
• Increased anxiety inhibits sexual arousal  

(Provisional) conclusion 

The (selective) attention of men with erectile problems focuses on performance-related, task-irrelevant and therefore non-sexual cognitions (“attention bias”). This selective attention increases when the pressure to perform increases, causing a decrease in attention to sexually arousing stimuli and a decrease in sexual arousal (“confirmation bias”).

Organic vs psychogenic cause 

Interview

• "spontaneous" erections
• Erectile failure during masturbation 
• Morning erections 
• Or NPT measurement (Nocturnal Penile Tumescence): a device that measures erections during sleep

Treatment options 

• Medications
• "injection" therapy 
• Penile prosthesis 
• Sex counselling 

Most common used medication

The pill does not give you an erection, you have to be active in sexual activities. 

Injection therapy: 

Androskat or Caverject. Relaxation of the muscles in the penis makes it easier for blood to flow through the penis. You don't have to be sexually active, the injection gives you an "erection". 

MUSE (Medicated Urethral System for Erection): a tube you put in the urethra, with a relaxation serum. (both not coverd by insureance)

Penile prosthesis: Not really an erection; "semi-rigid" vs "rigid"

Sex therapy for ED 

• Formulate attainable goals and the focus of therapy is to reduce performance anxiety and to improve (attention to) sexual arousal 
• Psychosexual education 
• Relaxation training (of pelvic floor muscles) 
• Sensate focus exercises 
  
  • Non-genital and genital touching 
• Communication about sex 
• A step-by-step introduction to sexual intercourse 
• Cognitive interventions: Rational Emotive Therapy   

What is "too fast" ejaculations 

Mean IELT (Intravaginal Ejaculation Latency Time): mean is around 5 minutes. 97.5% of men IELT>1,5 min. A condom does not make a difference. 

Premature ejaculation: etiology unknown; ejaculation within 1 minute and before the individual wishes it. 

Criteria

• Mild: IELT 30 seconds to 1 minute after penetration 
• Moderate: IELT 15 – 30 seconds after penetration 
• Severe: IELT 15 seconds after penetration 

Medication therapy 

• Antidepressants (SSRIs) “off-label”:  E.g. paroxetine, clomipramine (Effectiveness factor 2-7)
• Dapoxetine:  Effectiveness factor 2.5-3
• Local anaesthetic creams “off-label”:  Effectiveness factor 4-6   

Sex therapy

• Discuss goals / expectations (realistic) 
• Prohibition of coitus
• Pelvic floor muscle relaxation exercises (as an ejaculation control technique) 
• Stop-start exercises (alone and with a partner), manually (with and without lubricant), step-by-step during intercourse 
• “Acclimatization” 
• Cognitive therapy (RET) 
• Communication about sex  

Delayed ejaculation 

Criteria 

• Marked delay in ejaculation 
• Infrequency or absence of ejaculation 
• On 75-100% of occasions 

Causes 

• Physical (spinal cord injury) 
• Psychological 

Other factors 

• Less knowledge about high levels of sexual arousal • Absence of adequate sexual stimuli
• Specific, learned masturbation technique
• Inhibition of sexual arousal due to 
  
  • Performance anxiety and selective attention 
  • Anticipation of failure
• Avoidance of sexual activities because they offer low reward 
• Difficulty with control
• Lack of self-focused attention 

Treatment of Anorgasmia

Aim: "increase sexual arousal"

• Clear goals
• Masturbation training
• Look for sexual cues/stimuli
• (guided) fantasy exercises
• "Role play" (pretending)
• Use of vibrator
• Involving the partner
• Step-by-step plan towards orgasm during intercourse

Other orgasm problems (Unspecified Sexual Dysfunction)

• Retrograde ejaculation: orgasm but no ejaculation
• Anhedonic ejaculation: ejaculation but no orgasmic feeling
• Post-Orgasmic Illness Syndrome: Exceptional fatigue and exhaustion; Flu-like symptoms, muscle pain, etc.; Irritable, sometimes concentration problems; Maximum on the 2nd day after the ejaculation, symptoms persist for max. 1 week 

Other "Specified" Sexual Dysfunction

• Sexual Aversion
• Hyperactive Sexual Desire (Hypersexuality) 
• Genital Pain (during sex) 
• Body Dysmorphic Disorder

Sexual Aversion Disorder 

Persistent or recurrent extreme aversion for, and avoidance of, all or almost all genital sexual contact with a partner 

Inhibition of sexual desire due to 

• Negative sexual experience(s) 
  (sexual abuse) 
• Negative views about sexuality 
• Negative sensations during sexual 
  activities 

Treatment of aversion 

Cognitive Behavioural Therapy 

• Trauma therapy 
• Behavioural experiments 
• Exposure and response prevention 
• Counterconditioning (changing the negative associations into/towards a neutral or positive association) 
• Focusing on positive, rewarding aspects of sexuality 

Porn use: men watch more often porn than women. 71% of men watched porn in the past 6 months, in women that is 29%. Watching porn replaces or hinders, most people do not have sex with a partner. People who watch porn more often have sex with a partner. 

Hyperactive Sexual Desire (Hypersexuality/sexual addiction)

• Prevalence unknown
• Definition is unclear
• What is excessive 
• What causes it?

Causes 

• Alcohol / drug use (methamphetamine and cocaine) 
• Side effect of dopaminergic anti-Parkinson’s medication 
• Manic episode in a bipolar disorder 
• Neurobiological (e.g. Alzheimer’s) 
• Obsessive-compulsive behaviour pattern (comorbidity with paraphilia is high 

Treatment 

• Self-help groups 
  • On a religious basis 
  • On basis of addiction model “AA” 
• “Self-esteem building” therapy 
• Medication
  
  • SSRIs 
  • Anti-androgens 
• Cognitive behavioural therapy   

CBT Therapy

• Determine the “request for help” / goal of the therapy (concrete, realistic) 
• Ask about the unwanted behaviour. Under what circumstances? • Organism (sensitivity of system)
• Discuss the influence of alcohol/drugs
• Influence of androgens (psycho-education) 
• Stimulus control
• Response prevention 
  
  • “Limit” the unwanted behaviour 
  • Reward the wanted behaviour
• Build up a satisfying sexual relationship 
• Distract the attention
• Start to engage in and structure other activities / work
• Relapse prevention 

Sexual Pain Disorder

• Prevalence 0.2% - 8% (Simons & Carey 2001) 

• Dyspareunia (pain during sexual intercourse) 
• Phimosis(foreskin too tight) 
• Tight Frenulum 
• Peyronie’s disease 
• Infections / inflammations (STI) 
• Genital (chronic) Pain 
• Scrotal pain   

Treatment of Sexual Pain Disorder

• Operative intervention (circumcision)
• Pelvic floor physiotherapy
• CBT: For pseudo-phimosis: exposure/ “Consequences” (operant) model 

What is a "normal" size?

• Flaccid 
  • Length: 8.0 – 10.7 cm 
  • Circumference: 6.0 – 11.0 cm 
• Erect 
  
  • Length: 12.4 – 16.7 cm 
  • Circumference: 10.8 – 13.6 cm 
• Micropenis: 2.5 SD from the mean  

Satisfaction with penis size and importance attached to this by women and men: The distribution in terms of importance attached to penis length and girth is almost the same for both women and men (about 20%). Both sexes think that men regard penis size as more important than men themselves actually say. There is no correlation between penis size and sexual satisfaction (men and women).

Treatment: Self-help, operation and/or CBT

HC 6.1 Sexology Research 

Sex is: Physiological: erection; lubrication; breathing; heart ratel muscle tension; Emotional: excitement; desire; passion; ecstasy; satisfaction 

Measuring sex: Questionnaires: how accurate are people?; Psychophysiological methods: researching changes within the body.  

Specific psychological sexual responses

• Men: increase in the volume of corpora cavernosa, erection
• Women: increase in the volume of corpora cavernosa, increase in blood flow to the vaginal wall, lubrication

In the lab: measuring genital changes: 

• Barlow strain gauge: om de penis, tijdens het onderzoeken van de sexual respons, de penis wordt dikker, meten met dit apparaat
• Photoplethysmograph: measures blood flow in the vaginal wall, de horizontale plaat is buiten de vagina, zorgt dat het instrument altijd op dezelfde plaats is, dmv lichtsensor --> licht in de vagina, vagina reflecteert dit, measures the increase of blood flow (enorme piek kan zijn door beweging van de vrouw)   

Emotions: not only interest in the genitalia, but also what they experience 

To what extent did you feel: (0 = not at all; 7 = very strongly)

Sexual arousal; Pleasure; Shame; Anger; Disgust 

To do research in a lab, you need to expose participants to erotic stimuli:  Fantasy,  Erotic photographs,  Tactile (genital vibration),  Erotic film.

Possibilities for psychophysiological sex research?

• Effect of psychological (e.g. mood) and pharmacological manipulations, disease, surgical interventions
• Differences between people with and without sexual dysfunctions
• Sex differences (between men and women; or heterosexual and homosexual)
• Relationship between genital response and sexual feelings  

Issues in psychophysiological sex research 

• Accurate (objective assessment is an advantage)
• Small samples (selection bias): very time consuming, so small samples 
• Ethical (sex = private subject)
• All sex research needs to be approved by the medical ethical committee  

The role in consciousness and unconsciousness information processing in sexual arousal

Emotion-motivation theory is used by studying: neat and slow pathway vs quick and dirty pathway

(two different pathways in emotional responding). Quick responses are the reflex responses. 

fMRI study

Can sexual stimuli ‘automatically’ activate the emotion-motivation systems? Is this activation influenced by dopamine? Research with healthy young men and give them dopamine increase/decrease medicine. Showing masked sexual stimuli (not able to see the sexual stimuli). 

• Unconsciously processed sexual stimuli activate emotion-motivation systems in the brain
• Dopamine influences this activity: more increases it, less decreases it
• Further research: male-female, sex addiction, stress

What determines sexual feelings? Is this different in man and women?

Body <--> feelings

Correlations between genital and subjective sexual arousal are: Low in women; High(er) in men 

Hypothesis: women's sexual feelings are determined more by the evaluation of the context and nature of the stimulus. Maybe in men, the genital response is more important for their sexual feelings. For women, the context is more important for their sexual feelings. 

Meaning of stimulus & context:

• Meaning of the sexual stimulus: regular vs women-oriented erotica
• Film excerpts were matched in terms of nature and duration of the portrayed sexual activities 
• Measurement of genital responses & subjective sexual arousal in men and women 

Findings:

• Genital response: In men and women no significant differences between films 
• For men: feelings of sexual arousal equally strong 
• For women: experienced more feelings of sexual arousal by the women-oriented film

Conclusions:

• In women, the genital response does not predict sexual feelings
• In women, sexual feelings are determined more by meanings associated with the stimulus context
• In men, sexual feelings are determined more by the intensity of genital response

Implications for clinical practice? What do we learn?

Implication 1 

Unconscious activation: motivation process had already been activated before the individual is conscious of this. This helps in understanding why sexual responses can be difficult to control (such as hypersexuality). It also shows possibilities for pharmacological regulation.  

Implications 2

Research on the relationship between genital - subjective: automatic genital response is not evidence of positive sexual experience. It also shows that complaints of reduces sexual arousal does not necessarily indicate a disturbed genital response. Meaning of the stimulus and the context are important for women's sexual feelings. Pharmacological treatment aimed at increasing the genital response is an option for men, but not a solution for most women.

HC 7.1 Gender Dysphoria (GD)

Gender

• Gender social construct
• Gender role: behaviour
• Gender identity
• Gender dysphoria
• Transsexualism
• Transgenderism
• Travesty 

Background

Sex: all the physical aspects of the biological gender (chromosomes and physical anatomy)

Gender: the way someone identifies (psychosocial aspects of the biological gender) 

Gender role: behaviours, interest, preferences, personality traits, everything you can see on the outside

Gender identity: the way you identify within, the subjective feeling to belong to one of the genders, you can only know if you ask.

Gender identity problem: the incongruence between one’s gender identity and the biological sex at birth.

From pathology to normal?

Moving from pathology to a name, what will bring the future? 

Classification of Gender Dysphoria in DSM5

A A marked incongruence between the experienced/expressed gender and the assigned gender. It lasts at least six months, and is shown by at least two of the following…

1. A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics
2. A strong desire to be rid of of one's primary and/or secondary sex characteristics
3. A strong desire for the primary and/or secondary sex characteristics of the other gender
4. A strong desire to be of the other gender
5. A strong desire to be treated as the other gender 
6. A strong conviction that one has the typical feelings and reactions of the other gender

B Significant distress

How do you objectify "a strong desire"? You can have gender dysphoria if you feel like the other gender and want other people to treat you like that, even if you are okay with your own gender (you only need two points) 

DSM5 is a wide classification of gender dysphoria 

Change of perspective 

Gender dysphoria is a spectrum (or can we identify different kinds of gender)

Mild - Extreme --> treatment wishes are not always 'complete' 

New referrals per year: every year more and more. In 2018 900 new referrals, in 2019 they expect 1000 new referrals. Why so many more referrals every year? Does the media play a big role? There is a worldwide increase, they don't know where it is coming from? 

Way of treatment for children (<12) (below puberty)

Diagnostics

• GD? --> do they fit the criteria?
• General development
• Functioning: cognitive, emotionally, socially, school & family 

Psycho-education: to help keep open all possible developmental routes. 

-->for the majority the feelings of gender dysphoria diminish or disappear when they are adults, a big part doesn’t fit the criteria for gender dysphoria any more--> It can be a LHB orientation 

15.8% persisters; 84.2% desisters 

Way of treatment for adolescents

GnRH analogues to block puberty = completely reversible 

It is not a sex-affirming treatment; extended diagnostic phase:

• Create time to make a balanced decision
• Prevent (undesirable) physical development and to optimize psychological functioning 
• To increase 'passability' after sex affirming treatment 

Way of treatment for adults (18+)

Diagnostics

Aim

• What is the nature and degree of GD
• Exploring treatment wish and expectations (aren't they expecting too much?)
• Mapping one's capacity and coping strategies
• Giving advice for medical and/or psychological treatment
• Lifestyle (BMI, smoking, etc.)

Specific

• Gender development
• General development
• Sexuality
• Psychological & social function (incl. Comorbidity)
• Work or school situation 
• Partner relation and/or family situation (support and acceptance)

Development of gender: not all adults have experienced GD in childhood

Treatment of cross-sex hormones 

• Development of secondary sex characteristics
• Party reversible 

Feminisation (M-->F)

Masculinisation (F-->M)

Treatment surgery

Male --> Female

• Mamma augmentation
• Vaginoplasty

Female --> male

• Mastectomy
• Hysterectomy 
• Genital surgery 
  
  • Metaïdoioplasty: enlarging the clitoris
  • Phalloplasty: using a piece of your skin  

Take home messages 

• GD exists for a long time but has a recent steep rise in prevalence
• Unclear etiology (nature/nurture?)
• Cultural factors
• Has different developmental pathways (early and late onset)
• Differences in presentation and in treatment wishes and expectations
• Gender-affirming treatment is a thorough treatment (support is vital!)
• When uncertain how to address a person, ask him/her/them/it

HC 7.2 Paraphilic disorders

DSM 5: Distinction between paraphilia vs paraphilic disorders

Criterion A(Paraphilia): Intense and persistent sexual interest other than sexual interest for genital stimulation or courtship with a phenotypically normal adult consenting human partner. 

Criterion B: The paraphilia leads to suffering or limitations for the person involved or to negative personal consequences or risk of damage to third parties. 

The distinction because many people engage in atypical sexual practices, or paraphilias but a paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder and a paraphilia by itself does not automatically justify or require clinical intervention; in fact, a paraphilia is not a "diagnosis" 

Classification 

• Preference for abnormal activities (courtship disorders)
  • Voyeuristic disorder 
  • Exhibitionistic disorder 
  • Frotteuristic disorder 
• Algolagnistic disorders (algos= pain and lagneia= lust)
  
  • Sexual masochism 
  • Sexual sadism
• Preference for abnormal target
  
  • Pedophilic disorder 
  • Fetishistic disorder 
  • Transvestic disorder 

Typical psychopathological features 

Fixation: not just a preference for a given sexual stimulus, but a fixation on in, a complete sense of being bound to this one stimulus. 

Exclusivity: other sexual stimuli are of relatively little importance or significance. 

Destructivity: partner involvement is slowly lost, and the person is gradually caught in a limiting paraphilic scenario. 

Compulsion: sexual desire is gradually dissociated from relational, affective significance and reduced to uncontrollable hunger for stimuli. Increasingly risk-seeking behaviour as the urge becomes more compulsive.

Correlates with:

• Alcohol and drug abuse
• Other psychopathological disorders (Ax I and Ax II)
• Developmental disorder (autism spectrum disorder)
• Obsessive-compulsive sexual behaviour ("sexual addiction")
• Other forms of paraphilia

Difference in prevalence in men vs women

• Men greater biological plasticity --> they are more open to stimuli
• Men greater visual sensitivity 
• Paraphilic identity develops in a critical period of male sexual development around puberty, when sexual arousal to certain types of stimuli becomes an established pattern. For women sexual identity development is more secondary to social development 
• There is little difference, other than that cultural acceptance: women are less likely to recognize/express these desires 

Overview of the different paraphilic disorders

Common criteria

• At least for the duration of 6 months 
• Sexual urges or fantasies cause clinically significant distress or impairment in social, occupational or other areas of functioning 
• The individual is at least 18 years old 

Voyeuristic disorder 

Intense sexual arousal from watching unsuspecting (non-consenting) person engaging in sexual activities, getting undressed, or naked. At least 18 years old. Lifetime prevalence: men 11.5%; women 3.9

Exhibitionistic disorder 

Display of genitals to unsuspecting non-consenting stranger(s) (pre-pubertal children/physical mature individuals/both groups).

• Sometimes accompanied by masturbation 
• Usually no attempt to engage in further sexual activities 
• Surprise/fright effect is important 
• In some cases, sexually arousing fantasy that the stranger in question is sexually aroused
• Prevalence: men 2-4%, women unknown

Frotteuristic disorder

Experiencing recurrent and intense sexual arousal when touching or rubbing against a non-consenting person. 

• Age category: 15-25, decrease in behaviour after age 25
• Prevalence: men up to 30% reported; women unknown

Sexual sadism disorder

Experience intense sexual arousal from psychological or physical suffering of another person. Prevalence: men 2-30% (perpetrators of sexual violence 10%, perpetrators of manslaughter 37-75%); women 1.3% 

Sexual masochism disorder

Recurrent and intense sexual arousal while being humiliated, beaten, tied up or in some other way hurt or suffer. NB asphyxiophilia/auto-erotic asphyxia. Prevalence: men 2.2%; women 1.3% 

BDSM compared to control group (normal): 

• Less neurotic
• More extraverted 
• More open to new experiences
• Less scrupulous
• Less sensitive to rejection
• Experience higher level of subjective well-being

Fetishistics disorder

Experiencing intense sexual arousal from either the use of non-living objects or a highly specific focus on non-genital body parts (e.g. feet). The objects are not limited to articles of clothing used in cross-dressing or devices specifically designed for the purpose of tactile genital stimulation (e.g. vibrator). 

• Specify: body parts, non-living objects, other
• Prevalence: usually men

Transvestic disorder

Experience intense sexual arousal from cross-dressing (wearing clothing of the opposite sex), different than transsexuality because the reason for transvestic disorder is purely for sex.

• Specify: in combination with fetishism, in combination with autogynephilia (arousal from imagining oneself as a woman).  
• Incidence: men 2.8%, women 0.4%
• Easier to arouse
• 87% heterosexual, 13% homosexual/bisexual
• 50% experience it as ego-dystonic behaviour 
• Strong correlation with other paraphilic disorders (masochism/sadism/exhibitionism/ voyeurism)

Pedophilic disorder

Intense sexually arousing of fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child or children (generally 13 years or younger). Aged at least 16 or older and with an aged difference of a minimum of 5 years. Specify in exclusive type (only attracted to children), non-exclusive type, sexually attracted to boys, girls, both, limited to incest. Prevalence: men 3-5%, women unknown 

Change views over time: 1975 PSP party program: legalize the voluntary sexual intercourse of children with adult and child pornography. 

Different types

• Pedophilic type: a strong focus on children and sexual preference for children 
• Situational type: focus on children following a failed or unsatisfactory sexual relationship or contacts with sexual partners; incestuous and no permanent sexual orientation towards children; often arising from frustration, self-pity or social problems; rarely engage in physical violence, although they do use psychological manipulation
• Antisocial type: pedophilic abuse as part of general deviant behaviour and personality pattern, use of physical violence to force sexual contact on the child; often acts on an impulse
• Organic-pathological type: a psychosis or other mental or organic disorder at the root of the deviant behaviour 

Other specified paraphilic disorders: Telephone scatologia/ Necrophilia/ Zoophilia/ Coprophilia/ Klismaphilia/ Urophilia/ Apotemnophilia

Theoretical perspectives

Biological theories: there is a genetic susceptibility and/or defect (NB autism)/ dysregulation of neurotransmitters

Psychoanalytical perspective: disturbed psychosexual development, in which paraphilic symptoms represent an unconscious attempt to make the unconscious conflict bearable. 

Money: activation in puberty of a pathological ‘love scheme’, the basis for which is laid in childhood (in particular the 8^thand 10^thyear of life)

Courtship disorder: disturbance in normal human interaction sequence. Perceiving partner (voyeurism), pre-tactile interaction (exhibitionism), tactile interaction (frotteurism), genital union (rape). 

Cognitive-behavioural model

• Classic conditioning process (during early puberty) 
• Operant reinforcement 
• Lack of social sanctioning and correction (experimental behaviour that gets out of hand) 
• Cognitive distortion 
• Low self-regulation 
• Embedding in personal and social identity 
• Fragility in personal and social identity 

When treatment?

• When the suffering is severe
• When the behaviour is socially unacceptable (for instance problems in the family, with partner, social institutions, neighbourhood, work)
• Judicial coercion

Motivation for treatment tends to be extrinsic 

Treatment of paraphilia: 

• Surgery: castration, neurosurgery (not anymore)
• Drug treatment 
  
  • Psychotropic: Antidepressants in particular for regulation "impulse control"/"hypersexuality"/ SSRI's (Prozac, Zoloft, Fevarin); antipsychotics
  • "Chemical castration": anti-androgen drugs --> CPA/MPA; LHRH Agonists
• Psychotherapy
• Combination 
• Prevention/self-help

Adverse effects of drugs: 

Anti-androgen drugs: Weight gain, thrombosis, feminization, liver disease, inhibited spermatogenesis. Sometimes long-lasting effects: loss of fertility, loss of sexual desire/arousal

LHRH Agonists: Decrease in normal sexuality, hot flushes, hypogonadism, osteoporosis, reduced bone density

Cognitive behavioural therapy 

• Acceptance: “Learn to live with it”
• Decrease in “unsuitable” arousal, learning “suitable” sexual arousal (masturbatory reconditioning)
• Skills training: Social skills training / Aggression training
• Processing cognitive processes such as values, attitudes, and schemes
• Learning & optimizing relational skills (intimacy, attachment)
• Dealing with and resolving life challenges
• Preventing relapse
• Re-socializing

Treatment effectiveness 

• Little to no controlled studies with a lot of methodological shortcomings
• Effect difficult to measure: use of relapse or “lie detectors”
• Less discrimination: all paraphilic disorders studied together
• Limited effect of cognitive behaviour therapy and/or hormones 
• An important role of resocialization
• High social and political pressure

HC 8.1 Sexual Abuse

18% of women have been raped once in their lives, 1.4% of men are raped in their lives.

&8% of rape is committed by someone the victim knows. 24% is committed by a regular…. 

Men who are raped experience gender shame: they are ashamed to be a man.

"Have you ever been in a situation of unwanted sexual contact" OR "Have you ever been in situations in which you were forced to engage in sexual activities?"

Sexual Abuse: penetration (vagina, oral, anus)

Sexual Assault: everything else (not penetration)  

As a professional, you do not directly ask what happened. 

Why is it important to know if they told somebody --> it helps a lot for dealing with it, maybe that was a reason it stopped. 

Literature Child sexual abuse and consequences 

• More likely sexual re-victimization in adulthood
• More risky behaviour (younger onset of sexual activity, more partners, more likely to have unprotected sex)
• More sexual problems
• Fewer sexual rewards, lower sexual self-esteem
• More severe CSA, dysfunctional family dynamics, age > 5, worse sexual outcomes 

Sexual interaction competence (model) 

Zie bb 

• Background factors: family, how you were raised
• Mediating context: other important others (friends) 

Rape is an act of war, happens a lot during war 

Effects of sexual violence (model/formula): E (effect) = (S x F x M) / (A x Att x R)  

Sexual abuse in adulthood and consequences

The treatment of PTSD after sexual abuse seems not to effect sexual problems by itself. Current treatment for PTSD from sexual trauma does not appear to be addressing sexual problems. 

Treatment for PTDS: EDMR 

Consequences: 

• Women: Low sexual desire, vaginismus is lower by women who are sexually abused, dyspareunia is higher
• Men: hypersexuality, sexual identity problems, gender shame  

Sexual aversion (DSM-V): repetitive and extreme aversion (disgust and avoidance) of genital contact with partner.

How do women respond to treatments for sexual dysfunctions in treatment designs compared to women who are not abused?

Research after the treatment of women with lifelong vaginismus

• Never experienced intercourse, despite attempts
• The wish to have intercourse
• Heterosexual relationship > 3 months   

Therapist aided exposure --> does it work for trauma patients? It works, but a lot less. With sexual abuse, the mean time for treatment takes more time. 

Treatment is also effective for women with a history of sexual abuse  

Conclusions: 

• Exposure treatment duration increased
• Treatment outcome = partly moderated by sexual abuse
• Changes in negative and positive penetration beliefs are very comparable

Treatment of patients with sexual problems with a history of sexual abuse

• First discovery of one's own body
• Then sharing with partner
• Same approach as to other dysfunctions, but in general it takes more time and sometimes limited objectives
• Strong focus on one's own boundaries and slow tempo (create safe environment, important to stay in the here and now, sensate focus with eyes open, or soft talking)
• Attention to reduce anxiety and fear (relaxation exercises, counter-conditioning)
• More time spend on psychosexual education 

Open dialogue regarding potential physical arousal during sexual abuse: "it is known that women who were sexually abused might feel ashamed because their body reacted with physical arousal during the abuse although they didn't want the sex at all."

HC 8.2 Sex offender treatment 

Prevent offenders from re-offending.

10-15% will re-offend in 10 years 

What helps against re-offending?

• Punishment: consequences for the perpetrator 
• Don't have to be a judge, can be friends

The psychology of punishment 

(un)learning through punishment is most effective when: 

• Punishment should be consistent: always follows the offending behaviour (catch them)
• Punishment should be swift/quick: follows the offending behaviour as soon as possible (swift judicial process)
• Punishment is related to the offence (alternative punishments?)
• The punishment should "hurt", however, there is little relationship between penalty increase and recidivism-decrease (form painful to extremely painful does not help)

For those for whom punishment does not work, more punishment does not work either!

For all the possible benefits of punishment, rewarding good behaviour is almost always more effective (entice to conform)

Reducing recidivism, trough treatment of offenders 

What works?

Risk

Higher risk requires more intensive intervention: risk assessment! 

Justice centre's 5-level for general offender risk/need assessment

1. Prosocial, made mistake
2. Minor concerns
3. Typical problems for individuals in trouble with the law
4. Chronic rule violation, few strengths
5. Virtually certain to re-offend

For sex offenders instead of 'V' --> 'IVa' Chronic rule violation, few strengths; 'IVb' More and more severe 

Treatment:

1. No intervention needed
2. Case management 
3. 100+ hours of intervention; change focused community supervision
4. IVa en IVb 200-300 hours of change focused intervention; cascade of services.

No (intensive) treatment for low-risk offenders

• Waste of resources, the low risk will not decrease significantly
• When you do treat low-risk offenders, the will be disconnected from the protective parts of their life
• When they attend a group meeting, they will get in contact with high-risk offenders 
• Disconnected from the protective part of their life

Responsivity (requires customization)

The treatment must be offered in a way that matches the learning style of the offender 

Two kinds of patient-responsivity:

• Changeable factors: treatment goals
• Structural handicaps: adjustment treatment 

Sometimes treatment of responsivity factors is necessary to enable treatment of the risk factors

• Motivation: motivational interviewing 
• ADHD: medication, versatile and full program 
• Severe psychiatric problems (psychosis, depression): medication  

Sometimes the treatment needs to be adjusted to reach the patient 

• Intelligence: adjust level, non-verbal?
• Defective emotional life (PDD, Psychopathy): stringent and clear
• Narcissism: sparing, honourable way out
• Talents: use them! 

Need

Focus treatment on the offender's (most important) dynamic risk factors)

Sexual motivation cycle: see slides

Sexual motivation is a process, you go to the process a lot before acting

Physical arousal (sexual response cycle)

For men: there is already arousal in the body before noticing it. (initial (unconscious) sexual arousal)

Sexual motivation and offending behaviour 

(Dis)inhibition

• State disinhibition: intoxication
• Trait disinhibition: impulsivity
• 'choice' disinhibition: antisocial traits

You can train your brain to better act on temptation 

 What they teach: stay away from it, stay out of trouble. Avoid difficult situations  

• Medication: anti-androgens
  • Lowering or nullifying the sensitivity of sexual system (dopamine pathways)
• Aversive conditioning 
• Satiation therapy: do it so much, you never want to do it again
• EMDR: discards a stimulus of its emotional load, negative or positive 

If you take away deviant arousal, often means taking away everything (People want control, versus a cure) 

Summary: Learning to behave differently is certainly possible, 'even' for sex offenders; Learning to feel differently is more complicated, but might not be impossible; There needs to be informed agreement with the patient