Final (Ch 10, 11, 15, 16)

Question 1

Definition of Sex

Answer 1

• biological femaleness or maleness or intersex as indicated by genes, hormones, and physiology
• genetic sex is more complicated than chromosomal sex
• biological sex- a set of biological and reproductive characterisitcs to categorize individuals as being male, female, or intersex

Question 2

Definition of Gender

Answer 2

• the psychological experience of femaleness or maleness
• an emergent property of the biological and sociocultural factors that influence gender identity and gender roles

Question 3

SRY gene and its implications

Answer 3

• the gene that determines which gonad differentiating genes are expressed and found on the Y chromosome
• In a typically developing XY male the presence of SRY overrides the ovary promoting genes present on the X chromosome which results in male gonads, androgens at puberty, and a male-looking body
• In a typical developing XX female where there is no SRY gene and ovary-determining genes present, the ovaries will develop and secrete estrogens at puberty, resulting in a female looking body
• If SRY is expressed on an X chromosome in XX female, testes will develop, and individual will be phenotypically male
• If SRY is silent on a Y in XY male, ovaries will develop, and the individual will likely be phenotypically female

Question 4

Gender role and gender identity

Answer 4

• Aspects of femininity, masculinity, and gender diversity learned via socialization and culture, and enacted in our appearance, behaviors, and beliefs, as well as how our structures and systems are organized, will influence an individual’s gender identity
• Gender role is informed by gender schemas and stereotypes or attitudes about what are acceptable behaviors, attributes, and positions in society for men, women, and gender diverse people
• gender identitiy- internal experience of femaleness, maleness, neither or other(s)
• gender role- the set of social and behavioural norms that are considered socially appropriate for individuals of a specific sex in the context of specific culture

Question 5

Evolutionary psychology theoretical perspective on gender and sexuality

Answer 5

• understand g/s differences in sexuality as arising from evolutionary processes aimed at maximized reproductive fitness
• parental investment theory –> differences are due to potential reproductive outputs, which give rise to differences in gendered psychological processes and behaviours aimed at maximizing the likelihood that their offspring wil survive and reproduce
• Females can produce limited number of children = more conservative physiologically = lower sex drive, less sexual partners, want committed relationships
• Males have greater capacity to produce more offspring = less conservative = higher sex drive, more casual sex, preference for partners who exhibit characteristics associated w youthfulness
• traits associated w high RO are maintained via natural selection

Question 6

Social learning theory theoretical perspective on gender and sexuality

Answer 6

• gender differences in sexuality are the result of observational learning through media for example
• female sexual fluidity –> female sexuality is more malleable than male sexuality in reeponse to cultural influences

Question 7

Social structure theory theoretical perspective on gender and sexuality

Answer 7

• g/s differences in sexuality (in particular to mate preference) arise bc of gender binary division of power that emerges from a gender stratified workforce where men control resouces
• men are breadwinners and women are caregivers –> dictate appropriate conduct for men and women resulting in further gender differentaited behaviours
• Men are expected to take agentic roles, and be assertive, independent, and dominant
• Women are expected to take on communal roles by being relationship oriented, submissive, and dependent
• Gendered power inequality often manifests as the privileging of men’s sexuality, sexual objectification and dehumanization of women, and woman prioritizing the acquisition of long term means with resource is because they have limited means to provide for themselves

Question 8

Gender Similarities Hypothesis

Answer 8

• developed by Janet Hyde
• proposes that women and men are more similar than different for most psychological variables
• exceptions include psychological factors related to physical capacities like velocity and distance, special ability, aggressive behaviors, and in certain aspects of sexuality

Question 9

g/s differences in masturbation, numbers of partners, attitudes towards casual sex, and erotica use

Answer 9

• men report greater sociosexuality–> willingness to engage in sexual activity outside of commited relationship (more permissive attitudes toward and actual behaviour of casual sex) –> may be reflective of males greater reproductive outcomes and lower costs
• femlaes might strategically engage in casual sex at times of high fertility by choosing men w high reproductive fitness
• women’s interest in sex may fluctuate w menstrual cycle –> greater interest during ovulation
• gay men have similar attitudes and behaviour as straight, but may have more sex bc they are having sex w men w less conservative attitudes
• Straight men show significantly greater preference for youthful partners and significantly greater sexual jealousy or emotional upset then gay men –> likely due to bias towards females reproductive age
• Lesbian and heterosexual females did not differ in many aspects but lesbian women report greater interest in visual sexual stimuli , and heterosexual woman prioritized main characteristics associated with the ability to provide resources like social status

Question 10

g/s differences in sexual orientation

Answer 10

• show large g/s difference
• women are less likely to report exclusive different gender attraction
• women more likely to identify as bi, and report sexual attraction to both genders, and to have same gender contact
• as womens sex drive increases, so does their sexual attraction to both men and women –> no correlation seen in men
• cis female more likely than cis men to report some degree of same-sex attraction (more fluidity)
• bisexual and lesbian women are more likely to change identities overtime than gay or heterosexual men

Question 11

g/s differences in patterns of sexual response

Answer 11

• Women and men differ in two aspects of sexual response: specificity of sexual arousal and sexual concordance
• Men’s patterns of sexual arousal and genital response closely correspond to their stated sexual attractions to a man or woman, but heterosexual women’s do not
• Although women who are exclusively heterosexual report greater sexual arousal to stimuli depicting men than women, they also show genital responses to sexual stimuli depicting women
• For women awareness of genital arousal may not be a significant factor in determining their desire for a partner –> women experience automatic genital response to sexual stimuli; the lower concordance may often be produced by low reports of feeling sexually aroused
• Reporting biases and double standards may explain why studies repeatedly find that women’s minds and bodies are less in sync than in men

Question 12

g/d differences in reporting biases

Answer 12

• Men’s and women’s self-reports about their sexuality may be biased by desires to conform to gender norms
• Men tend to over report their partner numbers and women tend to under report which is consistent with a double standard whereby more liberal sexual attitudes and behaviors are tolerated in men but discouraged and woman

Question 13

Diversities of Sexual Development (DSDs)

Answer 13

• congenital conditions in which the development of anatomical, gonadal, and/or chromosomal sex is atypical
• true hermaphroditism refers to having both female and male reproductive organs, and is very rare in humans
• DSDs often identify as intersex
• Sex chromosome variations: Klinefelter’s, Turner’s
• Sex hormone variations: congenital adrenal hyperplasia, androgen insensitivity syndrome, 5-alpha-reductase deficiency
• Penile traumas and congenital variations

Question 14

Klinefelter’s Syndrome (XXY)

Answer 14

• most common sex chromosome trisomy disorder –> phenotypically male
• results from having two copies of the androgen receptor gene present on the x chromosome
• impaired feedback signalling to HPA results in high level of FSH, and lower level of testosterone
• usually not diagnosed till puberty –> gynecomastia, small testes, smaller penis, low testosterone, tall stature, compromised fertility
• many report low sexual desire, later onset of masturbation
• usually identify as males and are attracted to females
• typical treatment includes testosterone supplementation

Question 15

Turner’s Syndrome (XO)

Answer 15

• phenotypically female –> identify as female and intersex
• short stature, broad and widely spaced nipples, underdeveloped physical characteristics, and infertility
• often treated w growth hormones in children, hormones to induce and hormone replacement therapy through adulthood
• first masturbation and sex are typically reached at later stages

Question 16

Congenital Adrenal Hyperplasia

Answer 16

• autosomal recessive genetic disorder affecting cortisol synthesis that most commonly results in increased androgen production
• Individuals are typically exposed to elevated levels of androgens produced by their adrenal glands prenatally, and this exposure during the 6th week of gestation affects development of female fetus, causing varying degrees of virilization –> larger clitorises, partially fused majora, shorter vaginal length, incomplete differentiation of vagina and urethra
• the development of internal reproductive organs is typically unaffected in females
• Genetic males appearance is mostly unaffected –> often diagnosed at birth, but sometimes diagnosed a puberty when it may present as early onset of puberty accompanied by penile or clitoral enlargement
• half of women present w POS, which can lead to infertility, and many have compromised sexual function, pain and report lower arousability
• most women are heterosexual but some correlation btwn prenatal androgen exposure and degree of same-sex attraction
• girls might show lower nuturance and empathy and higher aggression (opposite for boys), and more interest in male-typical occupations
• dexamethasone decreases chance of passing on to offspring

Question 17

Androgen Insensitivity Syndrome

Answer 17

• X-linked recessive disorder where individuals born with XY chromosomes develop female physical characteristics but during fetal development, testes will develop under the influence of SRY, but generally do not descend
• As individuals develop, testes secrete typical levels of androgens but mutations in androgen receptor genes prevent the body from responding to the hormones, but they do respond to estrogens leaning to female-typical phenotype
• Individuals with partial AIS (PAIS) generally have intermediate male and female typical characteristics with differing degrees of general virilization
• Individuals with complete AIS (CAIS) have genitals that appear typically female, although the vagina may be shallower
• Most are assigned female at birth and are raised as girls, are heterosexual, and identify as women

Question 18

5-alpha reductase deficiency (5-ARD)

Answer 18

• results from mutations of the gene that encodes for 5-alpha-reductase 2- which is an enzyme that converts testosterone to DHT
• Individuals have usually undescended testes and typical levels of testosterone, so their internal reproductive organs are male, but because of the enzyme deficiency, external genitals develop as female typical (these tissues require DHT to virilize)
• Typically assigned female at birth and raised as girls until puberty
• When testosterone increases at puberty, virilization continues: the testes descend, the scrotum becomes pigmented, and the clitoris enlarges to resemble a small penis
• At this point most individuals will identify as men and are sexually attracted to woman
• Individuals may choose to undergo surgery to correct penile anomalies and may also choose hormone therapy

Question 19

Penile Traumas and Congenital Variations

Answer 19

• Some individuals are raised in a gender role different from their chromosomal sex for reasons other than a genetic disorder
• Physical developmental anomalies unrelated to sex chromosomes or sex hormones, search as penile agenesis, or cloacal exstrophy, resulting in a genetic male not having a penis
• For some individuals gender identities more strongly associated with genetic and hormonal sex than the assigned gender –> both nature and nurture play crucial roles in shaping gender identity

Question 20

Gender Development in Childhood

Answer 20

Gender development involves 3 related processes

• Detecting gender- being able to identify the similarities and differences between females and males
• Having gender- recognizing in oneself characteristics shared by either boys or girls or both
• Doing gender- matching one’s gendered behaviour w female or male gender stereotypes
• By age 1 majority of babies can detect gender, by two and three most children can identify what gender they have but they believe this to be a superficial characteristic, around age three to four children understand that gender is an inherent characteristic (gender constancy)
• Doing gender or behaving in stereotypic girl or boy ways emerges between the ages of 5 to 7

Question 21

Factors that shape a childs sense of gender identitiy and gender roles

Answer 21

• gender roles are imposed and babies’ behavior is interpreted through gendered lens
• Male and female children are temperamentally different: boys are notoriously more active, engaging in rough and tumble play and preferring active toys, whereas girls are typically less active and prefer playing with dolls and emulate nurturing
• Some believe that toy preferences (one expression of gender role and identity) are slowly the result of gender socialization, a process thought to be mediated by two forms of learning
• Observational learning- children watch and emulate the behaviors and choices of other children and adults
• Operational learning- gender conforming behaviors are reinforced and gender nonconforming behaviors are punished and children adhere to playing with toys that are prescribed for the male or female role in childhood

Question 22

Gender variation in Childhood and Adolescence

Answer 22

• Not all children adopt the gender identity or role strongly associated with their birth
• There is controversy surrounding the diagnosis of gender nonconforming children with gender dysphoria and treatment options
• The vast majority of gender nonconforming children desist in their gender dysphoria and grow to be happy and well-adjusted adults –> clinical practice of encouraging children to accept their birth sex and express their gender without medical intervention is the preferable approach to more irreversible medical interventions such as gender affirming surgeries

Question 23

Trans Identiities

Answer 23

• Birth-assigned males who identify as women are referred to as trans women, and birth-assigned females that identify as men are referred to as trans men
• Sometimes terms male-to-female (MTF) and female-to-male (FTM) are used
• Some people eschew gender binary altogether referring to a concept of a continuum of fluid gender, or choosing to identify as genderqueer

Question 24

Transitioning: Psychological and Physical Examination

Answer 24

• The first part of the process is psychological and physical evaluation by health care providers to diagnose gender dysphoria and rule out other mental concerns that might impact one’s experience and understanding of their gender
• This is especially relevant to those on the spectrum as there is significant overlap between gender dysphoria and spectrum disorders
• group therapy to connect and receive support
• need to ensure decision is only motivated by a strong desire to match physical attributes to their gender

Question 25

Transitioning: Real-life experiences

Answer 25

• social transition in which trans individuals fully transitioned to the social role matching their gender
• There is potential that the individual might face significant discrimination, so gender support groups are often beneficial

Question 26

Transitioning: Hormone Replacement Therapy (HRT)

Answer 26

• initiated under the care of an endocrinologist
• Trans men begin taking injections of testosterone causing male pattern hair growth on the face, chest, and body, deepening of voice, and changes in body fat distribution consistent with male typical pattern
• As testosterone accumulates in the system, menstrual period seizes, and clitoris becomes larger
• Many trans men also report increased sexual desire, more frequent sexual thoughts, stronger feelings of aggression, greater salience of social stimuli, and change in preference for visual sexual materials
• Trans woman began taking androgen blocking medications and estrogens
• Estrogens change body fat distribution to a more female typical pattern and cause skin to feel smoother
• Will also experienced breast growth
• most individuals must undergo electrolysis or laser treatments to remove facial hair permanently
• Androgen-blocking treatment typically reduces sex drive, and frequency of erections and ejaculations

Question 27

Transitioning: Gender-Affirming Surgery

Answer 27

• Recommended that it should start at least one year after hormone therapy begins and involves multiple surgeries to create genitals (bottom surgery) and chest contour (top surgery) associated with their gender
• For trans woman surgeries include bilateral orchidectomy (removal of testicles), and reconstruction of the penile and scrotal tissue to form a vulva (labiaplasty, clitoral construction), and a vaginal canal (vaginoplasty)
• Trans woman might also elect to have breast augmentation surgery, as well as raising vocal pitch, reducing prominence of Adams apple, and creating a more feminine facial and body appearance
• for trans men top surgery involves having a bilateral mastectomy, and cosmetic surgery to create a male typical chest appearance, and bottom surgery includes a complete hysterectomy (removal of the uterus), an oophorectomy (removal of the ovaries), and often scrotoplasty and phalloplasty (construction of a penis and scrotum) –> many ppl forgo phalloplasty
• Many trans men opt to obtain a metoidioplasty, a surgical procedure in which the enlarged clitoris is freed from the clitoral hood and a penile shaft is created and the result is a small erotically sensitive penis capable of an erection and orgasm
• Majority of trans people report satisfaction with their surgery an improvement to their quality of life after transitioning

Question 28

The choice not to transition

Answer 28

• Some transgender people do not transition to the other binary sex, rejecting the medical model of transsexuality, which suggests that transgender individuals have a medical disorder that requires a medical intervention to correct
• Individuals might have practical reasons for not fully transitioning such as medical conditions or they may reject the notion that they must choose one gender and possess all physical traits of that gender

Question 29

Sexual vs Affectional Orientations and Identities

Answer 29

• Sexual orientation refers to an individual’s tendency to be attracted to men and/or women; can overemphasize sexual aspects of what orientation is thus oversimplifying it
• The classic definition: a person’s erotic orientation- refers to which gender/ sex they are sexually attracted to and connections that are more meaningful to them
• Affectional orientation is a more inclusive term that talks about their identity and attraction irregardless of their behaviour

Question 30

Attempts to Measure S/A Orientation

Answer 30

• *Kinsey Scale:**
• best known scale that offers definitions of sexual orientation that range from exclusively heterosexual/different-gender/sex-oriented (a score of 0) to exclusively same-gender/sex-oriented (score of 6)
• placement on scale is primarily by self-reported behaviours and secondarily by self-reported sexual desires and attractions
• *Alderson:**
• more detailed and based on the sexuality questionnaire, and incorporates suggestions made by several researchers to measure affectional orientation
• Affectional orientation can operationally be defined and measured as a combination of 6 components: sexual attraction, sexual fantasies, sexual preference, propensity to fall in love romantically, being in love romantically, and the extent to which one has male and/or female partners

Question 31

Identity Labels

Answer 31

• labels are socially constructed and indicate more than just a preference for engaging in relationships w a certain sex, but also entail certain self-perceptions and world views
• Important factor of adopting a certain sexual identity label is that the identity it has a personal significance to the individual (e.g. females being called lesbian instead of gay)
• identity labels can change throughout life often because they were unaware of their romantic proclivities
• A percentage of men and women who identify as straight have had sexual encounters with same s/g
• Some individuals prefer not to use identity labels to describe themselves and some identify as queer (umbrella term)
• Lesbian/gay/bi are better used as adjectives instead of nouns –> identity

Question 32

Asexuality

Answer 32

• best definition: lack of sexual attraction to others –> no desire for sexual activity w others, and no distress over this
• low levels of sexual attraction, lack of interest in sexual behaviour, lack of sexual orientation, and /or lack of sexual excitation
• subjective aspects of sexual arousal don’t differ –> intact sexual response
• more concordance btwn subjective and genital measures of arousal
• not a disorder, and not celibacy (bc they dont want sex), and likely an orientation
• more likely to be women, cis, more religious, older, either single or in a long-term relationship

Question 33

Stages of Coming Out (Cass’ Rainbow Stairs) (6 Stages)

Answer 33

• *Identity confusion:** start to think of themselves as someone who is gay
• Same sex attracted feelings/ thoughts –> may be confusion or turmoil
• Can accept, repress, reject, and a whole host of other reactions people can have to this stage
• *Identity comparison:** accepts possibility of being same S/G oriented
• Gauging commitment to identity; implications of this potential identity
• Range of responses: may begin to embrace their identity or continue to deny their identity
• *Identity tolerance:** I probably am gay
• Acknowledge this is where they are
• Seek out others in community to decrease isolation and increase commitment to identity
• Want safe space for exploration of who they are as a gay person
• *Identity acceptance:** positive connotation associated with identity (vs. tolerance)
• Increased contact with others in the community
• Might begin selective disclosures (out in certain communities)
• *Identity pride**: this is who I am and I am happy about it
• Split: us vs them immersion (rejection of sexual majority)
• Less willing to blend in
• *Identity synthesis:** I am gay
• Integrate their sexual identity with all of their other roles
• More about “let’s all get together and work together” (us vs them integrating)

Question 34

Issues with Coming Out

Answer 34

• Less valid today: In the 70s –> coming out came with more issues because it was not discussed or represented in the media at all
• Varies across cultures (was associated w a lot of shame)
• Assumes permanence: the model assumes ppl’s sexual identity can’t change over time
• Assumes congruence: that people conform to the norms of their identity perfectly –> assumes that romantic attraction aligns w sexual attraction and labels fit all the behaviours one would expect

Question 35

Fluidity of Coming Out

Answer 35

• Women often come out more than once –> this is why they are seen as more sexually fluid
• Over time, change their label a lot
• Lisa Diamond: tracked women over 10 or 11 years –> 66% changed at least once, 25% changed 2+ times
• Lesbians: had period of other gender/ sex attraction
• Also had non gendered attraction –> attracted to a person regardless of their gender
• Men: sexual fluidity is most common in men who identity as bisexual–> Also seen in heterosexual men and same gender/ sex oriented men

Question 36

Frequency of Sexual Minority Status

Answer 36

• 3.5% of the US population in 2011
• Adults are 2-3 times more likely to say they have had same gender/ sex attraction or behaviour than they are to identify as a sexual minority
• Behaviours do not result in identity label always
• 2018 in Canada: 4%

Question 37

Heterosexism

Answer 37

• can occur both consciously and subconsciously, and either assumes these individuals do not exist, or projects a belief that they are somehow inferior
• heterosexist attitudes manifest most strongly as homophobia, biphobia, and queerphobia, which can lead to acts of hate and violence against SGD members

Question 38

Conversion Therapy

Answer 38

• Fear of same s/g individuals have led to attempts to change orientations to heterosexual orientations and are often driven by religiously motivated individuals
• Some highly motivated individuals changed their sexual identity, but this says nothing about affectional identity
• There is little evidence of long-term success of these conversion therapies as many ppl revert and ppl can change sexual identities throughout their lives
• serious ethical concerns as it targets certain individuals and attempts to “fix” a minority population deemed to have undesirable traits
• Conversion efforts seem out of line with the guideline to “avoid bringing harm to the client” that every reputable mental health professional is obliged to follow –> difficult to believe this is being followed as many individuals have a lot of adverse effects following such therapy
• For individuals who struggle same g/s identity, SGD-affirmative therapy is offered by ppl who view SGD individuals as being equal and may hold practise from any theoretical orientation –> more positive

Question 39

Theories of Affectional Orientation and Sex Identity Development

Answer 39

Question 40

Affectional Orientation Development: Biological Explanations

Answer 40

• Studies more focused on gay men bc more common and, more research, religious/culture its more focused on men –> certain genetic and immunological factors play a role in the development of affectional orientation
• A part of the hypothalamus in gay men is 2-3x larger, and that they have a larger corpus callosum
• Brain is activated differently (faster or slower) in gay men (compared to heterosexual men) and lesbian women (compared to heterosexual women)
• Left handed and men with more older brothers are more likely to be gay
• Prenatally exposed to too little testosterone = increased chance of identifying as gay, and too much testosterone = increased chance of identifying as lesbian or bi
• Genetic component to same g/s as twin studies found that components of sexuality are inherited and genetic influences can explain 42-60% of observed variance
• Structural and functional changes in the brains of transgender individuals –> consequences as brain adapts to new conditions the person experiences

Question 41

Affectional Orientation Development: Psychosocial Explanations

Answer 41

• Proposed that psychosocial factors heavily influence affectional orientation development and this development occurs as we process our experiences of ourselves interacting with others
• Michael D Storms proposed that s/a orientation emerges from an interaction between sex drive development and social development during early adolescence
• Personal construct theory posits that everyday social interactions underlie the development of both sexual identity and desires and explain why the stability and change in sexual identity through understanding the importance of experience and meaning in their development
• explanations remain theoretical and are less supportable as they become more specific
• *Signigicant insights:**
• Individual’s s/a orientation is not dependent on orientation of their parents
• Childhood abuse can cause psychological damage and lead to confusion regarding sexual identity, but there is no evidence that this can affect one’s affectional identity
• Same s/g individuals might question their identity more than heterosexuals but have always known to a certain degree
• Social and cultural influences can significantly shape how we understand and express our sexual and gender identity, but it is less clear that these influences have a great impact on our ability to fall in love romantically with ppl of particular s/g
• No etiological difference btwn how affectional orientation develops in gay men/lesbian women, but develops differently in women than men

Question 42

Sexual Identity Development

Answer 42

• only theory that received any popularity in the past was the sociocognitive one developed by Vivienne Cass (6 stages of coming out)
• Kevin Alderson proposed the ecological model of SGD Identity- based on the human ecology theory that ppl interact w their environment, and through examination of these interacting influences, the quality of life can be improved by creating healthy human environments
• Recognizes that a person’s SGD identity occurs within a complex environmental shaped by the society in which the individual lives in, cultural/spiritual, parental/familial, and peer influences
• If SGD individuals can question their identity, they will begin to reflect upon their behaviour, cognition and affect and if their analysis of these personal dynamics suggests an SGD identity, they may assume that identity
  Will also involve:
• Inner psychological work with/w out a therapist
• Connecting to SGD culture
• Reconnecting w this new identity to the dominant culture
• If that is accomplished they will then move to final stage where they develop a consolidated sense of their unique SGD identity

Question 43

Self-Identification as Lesbian, Gay or Bisexual

Answer 43

• Every theory of sexual identity formation requires the self-identification process to occur before a positive identity can develop (essential for emotional health)
• internalized homophobia/biphobia can block self-identification processes either through denial, a destructive defence mechanism, or self-loathing –> biggest barrier to developing positive identity
• Erik Erikson believed people need to have a secure identity before they can become capable of true intimacy and love
• Those who dislike or hate their affectional orientation can develop very negative sequelae and may engage in harmful behaviours like unprotected sex

Question 44

Identity Disclosure (SGD)

Answer 44

• dependent on many personal and environmental factors
• In some countries, disclosing a gay identity may have serious social and even life-threatening consequences
• disclosing at younger ages over past few years
• disclosing is associated with having better physical and mental health (lower incidence of many diseases)
• parents and workplace discrimination can be barriers
• May be risky for sexually diverse individuals who are in communities where homophobia is highly prevalent –> fear of being ostrasized

Question 45

Same s/g Intimate Relationships

Answer 45

• regardless of sexual identity, the more committed people are in their relationships, the better their sense of well-being
• Lesbian couples tend to report greater satisfaction than gay or heterosexual –> desire for equality, value of emotional intimacy, attachment styles, conflict resolution, high self-esteem
• For gay men, relationship satisfaction does not depend on monogamy; CNM couples seem to be just as satisfied in their relationships
• Regardless of affectional orientation, men are more inclined to look for an attractive partner and woman place greater value on personality and tend to be more expressive in their relationships
• Same g/s partners are more likely than mixed g/s partners to remain friends after relationship dissolution, less likely to seek partners whose demographic characteristics are similar to their own, and tend to be less controlling and use fewer hostile tactics during conflict
• Internalized homophobia is one of the most serious obstacles to establishing and maintaining same s/g relationships

Question 46

Bisexuality and Relationships

Answer 46

• Freud believed that we are all constitutionally bisexual
• *Components of affectional orientation**
• changes in sexual attraction mechanisms occur overtime –> bisexuality may be lost to socialization
• ppl have sexual fantasies of both genders
• ppl prefer sex w diff gender, and needed to sustain population, but this doesnt rule out interest in having sex w same s/g
• who we acc have sex w depends on a lot of factors
• observation evidence doesnt seem to suggest that most ppl fall in love romatically w members of both sexes

Question 47

Bisexual Individuals in Relationships

Answer 47

• Most bisexual individuals enter mixed s/g relationships long before they begin exploring their same g/s interests
• Bisexual men and women are more emotionally attracted to women but more sexually attracted to men
• Most maintain monogamous relationships and some choose to establish CNM
• Because of the small percentage of individuals who define themselves as bisexual, a substantial community does not exist –> many individuals report feeling isolated, some in part because many view bisexual individuals as “fence-sitters”

Question 48

Bisexuality from Lec

Answer 48

• Most accurate definition: a sexual or affectional orientation in which affect (outward expression of internal emotions) and cognition are directed at both/all sexes/genders to some extent (behaviour may or may mot be contrugent)
• Less acceptance for bisexual men
• Study in the 1970s: Kurt Freund –> bisexual men came into the lab and measured penile response (with penile strain gauge) to men and women
• Stronger penile response to men
• Drew conclusion that no men are bisexual –> penile response is only one part of affectional orientation
• Not everyone is equally attracted to everyone, male images could have been more arousing, may only have emotional attraction to women
• Sometimes this label is temporary: 40% of gay men used bisexual as a palce holder
• More accepted in women: more sexually flexible on average (or seen as more sexual flexible)
• Study in 2006: more common in women than in men (almost double), homosexuality less common in women

Bisexuality stereotypes:
o Confused, indecisive (sitting on the fence)
o Not trustworthy
o Non-monogamous
o Sexually promiscuous
o Open minded, open to new experiences

Question 49

Same G/S sexual behaviour

Answer 49

• Gay men in relationships have the most sex, lesbian couples have the least, and mixed g/s fall somewhere in between
• The amount of sex overtime diminishes for all relationship types, and gay couples tend to become less monogamous
• Gay boys report having sex with other boys around 13 or 14 and lesbian girls around 14 or 15
• Most adolescent gay boys have had manual oral sex with another boy and half have tried oral-anal contact
• The typical order for sexual activities in gay boys is: oral sex, anal sex, anilingus, and anal-dildo penetration
• For WSW, order is: oral sex, vaginal-digital penetration, anilingus, vaginal-dildo penetration, and anal-dildo penetration
• Most common MSM practices in order of prevalence: mutual masturbation, oral sex, and anal intercourse
• Most common WSW practices in order of prevalence: oral sex, vaginal-digital penetration, and mutual masturbation –> genital-genital contact, esp scissoring and other forms of tribadism
• Study found women in same s/g relationships experienced more orgasms from a variety of activities compared with women in mixed s/g relationships and enjoy longer durations of sexual behavior –> women in same g/s relationships are more adept at knowing how to sexually please another woman

Question 50

Parenting and Adoption by Sexually Diverse Individuals

Answer 50

• Research suggests that same g/s relationships are not appreciably different from mixed g/s ones, and parent’s orientation has no bearing on their capacity to provide a safe, healthy, and nurturant environment for children
• Some families even demonstrate more competences and express fewer behavioural problems than children raised by mixed g/s parents
• Parental sexual orientation is unrelated to outcomes regarding socialization of children, but psychological outcomes are better when two parents raise a child instead of one and variables such as parental g/s, marital status, and sexual identity appear to have no measurable effect
• In Canada same-sex couples are legally entitled to adopt children but are less likely to be matched than mixed g/s couples

Question 51

Paraphilias vs. Paraphilic Disorders

Answer 51

• Paraphilias refer to intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling w the phenotypically normal, physical mature, consenting human partners
• sexual arousal/response depends on something that is atypical
• paraphilic interests can be inclusive or exclusive, and range on a continuum
• Parapaphilic disorders cause distress or impairment to the individual or a paraphilia that causes personal harm, or risk of harm, to others when acted upon
• unable to have sexual response w out object, partner feels neglected

Question 52

Diagnosing Paraphilic Disorder

Answer 52

• Criterion A: Atypical sexual interest as manifested by fantasies, urges, or behaviours
• Criterion B: specifies the negative consequences (distress, harm)
• both criteria need to be met
• 6+ months
• true paraphilics disorders are rare and tend to cluster

Question 53

Categories of Paraphilic Disorders

Answer 53

• *Anomalous Activity Preferences:**
• Courtship disorders –> Voyeuristic, Exhibitionist, Telephone Scatologia, Frotteuristic
• A**lgolagnic disorders –> sexual sadism and masochism
• *Anomalous Target Preferences:**
• Directed at humans –> pedophilic Disorder
• Directed elsewhere –> fetishistic disorder, travestistic disorder, other unspecified
• hypersexuality

Question 54

Voyeuristic Disorder

Answer 54

• Voyeuristic disorder is diagnosed when an individual has recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, and/or engaging in sexual activity, as manifested by fantasies, urges, or behaviors
• In addition, either the person has acted upon these urges with a non-consenting person, or the urges and fantasies have caused distress or impairment (6+ months)
• Minimum 18 years of age for a diagnosis to be made as they don’t want to pathologize adolescents
• The unsuspecting piece of the definition is a key component of their sexual arousal as fear of getting caught adds to the arousal of a voyeur, but they don’t actually want to get caught
• associated w crimes like b&e
• Voyeurism rarely leads to more intrusive sexual activities such as assault, and there is a positive association between voyeuristic behavior and more psychological and substance-use problems, lower life satisfaction, and greater sexual interest

Question 55

Exhibitionistic Behaviour

Answer 55

• Involves recurrent and intense sexual arousal from the exposure of one’s genitals to unsuspecting person
• individual must have acted upon these urges with a nonconsenting person or experienced distress or impairment from the fantasies (6+ months)
• victims reaction is reinforcing and they want a positive reaction
• most common of the lawbreaking sexual behaviours
• masturbate to ejaulation while exposing themselves

Question 56

Telephone Scatologia

Answer 56

• Diagnosed under the category of other unspecified paraphilic disorder but shares features with exhibitionistic disorder
• A form of verbal exhibitionism in which a person becomes aroused by making sexually explicit phone calls, based on the reaction of the victim
• The caller may masturbate during the call or while thinking about the call afterwards
• Charges for making such calls can include sexual harassment and stalking

Question 57

Frotteuristic Disorder

Answer 57

• Characterized by the act of fantasizing about, or actually engaging in, rubbing against or touching (toucherism) a non-consenting person for sexual gratification
• individual must either have acted upon these urges with a non-consenting person or experienced distress or impairment from the urges or fantasies
• These behaviors usually occur in public, crowded areas where, if caught, the perpetrator can claim that the rubbing or touching was an accident
• highly comorbid with exhibitionism and voyeurism

Question 58

BDSM

Answer 58

• Engaging in sadism or masochism with a fully informed, willing, and consenting partner is considered part of the BDSM/kink community
• Each areas within BDSM consist of consensual sexual behaviors, and although there are some sexual sadists who engage in non-consensual sexual activities, these practices are not related to the subculture of BDSM/kink
• *Bondage and Discipline (BD):**
• Bondage is the use of restraints, and discipline may include painful whipping, biting, hot wax, or other painful stimuli
• It may also include sensory deprivation and humiliating behaviors, such as bootlicking or behaving like a dog, or the use of feces or urine
• *Dominance and Submission (DS):**
• DS is about elaborate place groups that can be specific to sexual interactions overall areas of relationship
• The dominant partners often referred to as the “master” or the “top”, and the submissive partner is often referred to as the “slave” or “bottom”, and individuals can also be a “switch”
• *Sadism and Masochism (SM):**
• Rituals and scripts surrounding the infliction of pain (sadism), or the receiving of pain (masochism) in a sexual context –> don’t find pain outside of sexual context arousing

Question 59

Sexual Sadism Disorder

Answer 59

• A sexual sadist is someone who derives sexual pleasure from inflicting physical pain or psychological suffering on another person, often to gain power or to humiliate the other person
• Sexual sadism disorder involves recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors
• For a diagnosis to be made, one must have acted upon these urges with a non-consenting person, or the sexual urges or fantasies must cause significant distress or impairment
• Goals are to gain power and humiliate, causes harm to others and is non-consensual

Question 60

Sexual Masochism Disorder

Answer 60

• A masochist is a person who derives sexual pleasure from experiencing pain, humiliation, or suffering
• Sexual masochism disorder involves recurrent and intense sexual arousal from the act of being humiliated, bound, beaten, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors
• For a diagnosis to be made, one must have acted upon these urges with a non-consenting person, or the sexual urges or fantasies must cause significant distress or impairment

Question 61

Theories of Development of Sexual Sadism and Masochism

Answer 61

• Some theorists have proposed that sadomasochism develops based on certain childhood or adolescent experience
• e.g. being punished after being caught masturbating as a child may lead one to associate pain or humiliation with sexual arousal
• Masochism may also be explained by a desire to escape from self-awareness and remove pressures and responsibilities of everyday life –> relinquish control to another
• For the sadistic partner, the treatment of the submissive as a vehicle for their own sexual pleasure may diminish some of the anxiety associated with sex

Question 62

Pedophilic Disorder

Answer 62

• Sexual interest in children who are not of reproductive maturity by biological standards (i.e. those who are prepubescent or pubescent) is considered paraphilic
• The diagnosis of pedophilic disorder is specifically for individuals who have recurrent, intense, sexually arousing fantasies or urges involving sexual activity with the prepubescent child or children, generally aged 13 or younger, and who have acted upon these urges or in whom the urges or fantasies caused marked distress or interpersonal difficulty
• We shouldn’t minimize the negative impact of online defences as more demand means more child pornography and more children harmed in the creation to meet said demand –> but online interests dont necesarily result in contact offenses
• Most pedophiles do not prey on strangers and most are nonviolent but rather work hard to groom and coerce a specific child they are close to
• Incest offenders have significantly lower rates of recidivism compared to non-incest offenders, and only female child victims and older offenders have significantly lower recidivism rates

Question 63

Critism of DSM-5 Definition of Pedophilic Disorder

Answer 63

• exclusion of specifiers that would increase accuracy of diagnosis by specifying whether the individual is attracted to prepubescent children, pubescent children, or both
• The age of 13 is also criticizes being an arbitrary cut-off, as pedophilia is not so much about the actual age of a child as about the physical characteristics and lack of maturity
• criterion B seems to be redundant since anyone with sexual fantasies, urges, or behaviors toward children in our society will be socially impaired in some way, due to our societal norms and laws against such attraction
• The definition also seems to allow for the disorder to be diagnosed on the history of sexual acts alone, thereby blurring the line between mental disorder of pedophilia and criminal sexual acts against children
• There is overlap but a person who sexually offend against children and people who are diagnosed as pedophiles or not the same

Question 64

Fetishes and Fetishistic Disorders

Answer 64

• The term fetish was originally used to describe urges, fantasies, and behaviors in which nonliving objects or specific body parts (partialism) are eroticized
• Fetishistic disorder involves the persistent and repetitive use of or dependence on non-living objects or a highly specific focus on a body part as a primary element associated with sexual arousal; this focus must cause significant personal distress or psychosocial impairment (6+ months)
• The fetish cannot be limited to articles of female clothing exclusively used in cross dressing or to devices specifically used for tactile genital stimulation such as vibrators
• In extreme cases the individual’s unable to orgasm or even become aroused unless the fetish object is present, and in milder cases the object does not play a central role in one’s sexual experience but acts to enhance it
• exclusively in men
• most directly related to human body or related objects, and feminine

Question 65

Transvestism and Travestic Disorders

Answer 65

• Many individuals who cross-dress do not meet DSM-5 criteria for transvestic disorder
• The diagnosis of transvestic disorder applies to individuals whose cross-dressing or thoughts of cross-dressing are always or often accompanied by sexual excitement and who are emotionally distressed by this pattern or feel that it impairs social or interpersonal functioning (6+ months) –> items have to be worn

There are two specifiers for this diagnosis in men:

• If an individual also reports sexual arousal to the fabrics, materials, or garments he is wearing, he is diagnosed with transvestic disorder with fetishism
• If the individual is sexually aroused by thoughts of himself as a woman, he is diagnosed with transvestic disorder with autogynephilia
• presence of the specifier of autogynephilia increases the likelihood of gender dysphoria in men with transvestic disorder

Question 66

Other Specified Paraphilic Disorders

Answer 66

• *Erotic Asphyxiation (breath control play):**
• Intentional restriction of oxygen to brain for the purpose of sexual arousal
• Need to do it w someone around bc can result in death
• *Cuckholdism/cuckqueanin, troilism:**
• Sexual pleasure derived from seeing one’s partner engage in sexual activity with another person, or from knowing that one’s partner is having an affair

Question 67

Hypersexuality

Answer 67

• Hypersexuality is an excessive, insatiable sex drive that leads a person to continually pursue sexual encounters despite negative consequences
• Refer to as nymphomania in women and satyriasis in men
• Some researchers characterize hypersexuality as a dysregulation in impulse control, resulting in excessive frequency and intensity of maladaptive sexual behaviors, and other models are based on the principles of addiction and compulsivity
• It can be hard to quantify what an excessive frequency of sexual behavior is, so individuals who meet their proposed criteria have significant impairment in their relationships, work, and education because they spend so much time thinking about pursuing sexual activities

Question 68

Development of Paraphilias/Pharaphilic Disorders: Psychoanalytic Theory

Answer 68

• According to this theory paraphilias are thought to result from castration anxiety and the Oedipus complex (common in men)
• The fetish object is an unconscious replacement for the mother’s missing penis and therefore reduces castration anxiety evoked by the missing penis of a female partner
• The fetish object is hypothesized to be the object last seen by the boy prior to his realization that his mother does not have a penis (something feminine)
• all paraphilias are hypothesized to involve issues about masculinity or femininity
• Object-relations theorists proposed that sexual abuse or trauma in early childhood results in an inability to maintain healthy sexual and romantic adult relationships

Question 69

Development of Paraphilias/Pharaphilic Disorders: Behavioural Theory (3 points)

Answer 69

• Goes along with Freud’s theory of children being polymorphous perverse –> can be aroused by anything
• development of paraphilias occurred through classical conditioning in which the paraphilic object or action becomes paired with sexual arousal over one or more trials in which the sexual arousal is accidentally associated with it
• According to John Money, a child may redirect sexual energy towards a permitted object if normal sexual curiosity is punished or discouraged
• In men, this association may also occur accidentally through the experience of an unanticipated erection being associated with whatever activity that person is involved with at that time
• Objectification of women and sexualization of certain objects in the media may also explain paraphilias

Question 70

Development of Paraphilias/Pharaphilic Disorders: Neurological Findings

Answer 70

• Neuro-cognitive testing has demonstrated that pedophiles have lower IQs and are more likely to have repeated school grades or received special education
• Brain imaging studies show that pedophiles showed deficits in brain activation associated with sexuality when they’re viewing sexual pictures of adults and significantly more activation in emotional processing areas of the brain (amygdala) when looking at pictures of children in swimsuits
• A decrease of white matter volume of the temporal and parietal lobes, and deficits in cortical regions known to be associated with the recognition of sexual stimuli have been seen in pedophiles
• differences in functional connectivity within areas of the brain that are associated with responding to sexually relevant stimuli
• Studies suggest that people with certain brain characteristics may have a susceptibility to pedophilia

Question 71

Theories of the development and maintenance of Pedophilic Disorders

Answer 71

• More research has been done on pedophilic disorder then on other paraphilic disorders because of the high prevalence of men who were arrested for child sexual offences
• may stem from sexual abuse suffered as a child –> a high proportion of child sex offenders were abused as children
• behavioral characteristics may be more likely to develop pedophilic disorder or commit sexual offences against children:
• Sexual deviance (e.g. pedophilic disorder), antisocial traits, and intimacy deficits including poor social skills an identification with children, are all behavioral risk factors for developing pedophilia
• pedophiles who sexually abuse children likely suffer from thinking errors (cognitive distortions)
  o Cognitive distortions are often statements that individuals make to themselves that serve as excuses to allow them to rationalize, justify, minimize, or deny that they are behaving in an inappropriate manner

Question 72

Sex Differences in Paraphilias

Answer 72

• Paraphilias are much more common in men than women
• difference is due to evolutionary sex differences based on males being able to inseminate multiple female partners for biological fitness –> From this POV it would be beneficial for males to become aroused by a variety of stimuli that do not contain emotional content such as fetish objects
• Another explanation is based on the observation that it may be the combination of sexually explicit stimuli and widespread prohibitions about sexual behavior that drives some paraphilias –> may partially explain difference because most of the sexual stimuli in western culture are aimed at a male audience

Question 73

Assessment of Paraphilic Disorders

Answer 73

• Assessment consists of an interview including a general background of the client, a mental and physical health history, and an extensive sexual and relationship history
• Malingering (exaggerating) and downplaying symptoms should also be assessed
• Assessment may also include psychometrics like intelligence tests, personality inventories, and measures of mental health
• For research purposes and in criminal cases, particularly those involving offences against children, phallometry may be used to assess paraphilic interests
• The two methods for collecting data on penile blood flow are: the circumferential method using penile strain gauge, and the volumetric method
• Criticism for the use of phallometry include the lack of standardization, in the fact that clients can manipulate or also by enhancing or suppressing it as they deem appropriate
• Physiological testing measures are not used in cases of sex offenders who are a woman as women become genitally aroused by a variety of sexual stimuli, including stimuli that they do not rate a subjectively arousing
• Polygraph tests may also be used in the assessment and risk management of sex offenders –> it might increase the number of truthful disclosures because of the “bogus pipeline” paradigm in which people reveal more just based on the belief that the device can detect their lies

Question 74

Treatment of Paraphilic Disorders: CBT and Relapse-Prevention Techniques

Answer 74

• Most sex offender treatment follows the CBT model, usually paired with relapse prevention (RP), and done in a group setting (social-skills component) –> gold standard
• Treatment intensity depends on recidivism risk
• This model focuses on challenging offenders cognitive distortions about sexual offending, encouraging the offender to empathize with others, getting the offender to take responsibility for offending, identifying personal risks for offending, and developing personalized safety plans to address those risks

Question 75

Treatment of Paraphilic Disorders: Self-Esteem and Social-Skills Training

Answer 75

• Self-esteem and social skills training is typically done in group settings in conjunction with the CBT/RP model
• intended to target the risk factor of loneliness and to help build social skills for engagement with age-appropriate colleagues and future partners
• Assertiveness, anger, impulsivity, mood management, and healthy relationships topics that may be covered in this training
• Development of social skills and reintegration into society are important factors in reducing recidivism –> often society only focuses on punishment

Question 76

Treatment of Paraphilic Disorders: Mindfulness and Emotional Regulation

Answer 76

• Many sex offenders have difficulty with emotion regulation, which may contribute to initial offending as well as to recidivism
• Mindfulness-based treatments have been suggested as an appropriate treatment method to target this risk factor
• Mindfulness includes learning self-regulation and attention to present moment as well as maintaining a curious, open, nonjudgmental, and accepting attitude
• This approach fits nicely with existing approaches such as CBT

Question 77

Treatment of Paraphilic Disorders: Satiation Therapy

Answer 77

• Requires the client to masturbate to an appropriate fantasy and then masturbate again immediately following orgasm to an undesired fantasy
• the decreased sex drive on the second masturbation attempt will make the experience less exciting and eventually the pairing between the undesired fantasy and sexual arousal will diminish

Question 78

Treatment of Paraphilic Disorders: Orgasmic Reconditioning

Answer 78

• Requires a client to masturbate to the paraphilic fantasy until the point of orgasm, at which time the fantasy is switched to a more socially acceptable one
• The goal is for the client to come to associate orgasm with a more appropriate stimulus

Question 79

Treatment of Paraphilic Disorders: Aversion Therapy

Answer 79

• Fantasies of the paraphilic behavior are linked with an unpleasant stimulus, such as an unpleasant smell or an electric shock
• meant to condition the client to associate the unpleasant stimulus with paraphilic behavior so that they no longer associate the paraphilic behavior with pleasure

Question 80

Treatment of Paraphilic Disorders: Community-Based Support Programs

Answer 80

• Community based support programs for hypersexuality are often modelled on the 12-step program of AA, and are often used to treat sexual addictions
• Examples include sexaholics anonymous (SA) and sex and love addicts anonymous (SLAA)
• Community based support programs are also offered for sexual offenders including circles of support and accountability (COSA)

Question 81

Treatment of Paraphilic Disorders: Medical Treatments

Answer 81

• Paraphilic disorders that have resulted in legal repercussions, or that have not responded well to other treatments, may warrant pharmacological treatment starting with a course of antidepressants
• if these are not effective within 4-6 weeks a small dose of anti-angrogen may be added to reduce sex drive –> injections are preferred method for ensuring treatment adherence and monitoring for cases that involve criminal activity
• Chemical castration is not always an effective treatment option for reasons such as:
  o compliance with chemical castration do to adverse effects
  o The reduction of sex drive is not only limited to sexual arousal related to the paraphilia so chemical castration is likely to interfere with other treatments designed to encourage appropriate partnered sexual activity to reduce risk of recidivism
  o Patients may decide to take sexual enhancement/erectile functioning drugs to overturn the effects
  o This treatment may not be useful for particularly violent offenders or those whom the ability to achieve an erection is not part of the offence

Question 82

Sexual Dysfunctions Overview

Answer 82

• clinically significant disturbances in a person’s ability to respond sexually or to experience sexual pleasure, and needs to be present for 6+ months
• organized around Kaplan’s sexual response cycle, and can interfere at any point (desire, arousal, orgasm)
• Distress doesn’t always come with dysfunction –> people can be sexually satisfied if they have sexual problems (only diagnosable if distress, or a problem for partner bc that causes relational issues)
• Can still treat distress even if there is no dysfunction (distress can occur without dysfunction also)
• comorbid w mood disorders, and these disorders take precedence

Question 83

Dimensions of Sexual Dysfunctions

Answer 83

• *Onset**- either lifelong/primary, or acquired/ secondary
• *Context**- generalized (occurs in all sexual experiences both partnered and alone) or situational (e.g. fine in solo activity, but issues during partnered)
• *Severity**- mild (1-3) to moderate (4-6) to severe (7-9) based on how the patient feels (may not always align w what the therapist suspects)
• Dimensions are important for treatment outcomes as primary and generalized are usually more difficulty to treat than secondary and situational

Question 84

Diagnostic Process for Sexual Dysfunctions

Answer 84

Need to consider many variables:

• Partner factors –> low desire bc don’t trust partner, partner has dysfunction, no pleasure within TSS
• Relationship factors
• Individual vulnerability factors –> trauma, SA
• Psychiatric and medical comorbidities –> depression, and chronic pain disorders
• Stressors –> massive shift in life
• Cultural/religious factors –> boundaries for sex therapist, prohibitions may play a role in personal distress
• Age, adequate sexual stimulation, cultural expectations, lifestyle, overall health, etc.
• Need to account for complexity of sexual function, accept that etiologies are usually unknown, and rule out other issues that would preclude a diagnosis of sexual dysfunction (refer to other medical professionals)

Question 85

Genitopelvic Pain/Penetration Disorder (GPPPD) (Notes have more stuff from TB, but imporant?)

Answer 85

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

• Vaginal penetration during intercourse (ranging from pain in all activities to just sexual)
• Vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts
• Fear/anxiety about pain in anticipation of, during, or as a result of vaginal penetration
• Tensing/tightening of the pelvic floor muscles during attempted vaginal penetration –> body will guard area that is sore/painful and is a natural protection response
• Can often cause dyspareunia (painful intercourse) and can result from underlying pathologies such as emdometriosis, gnetial infections, interstitial cystitis, but also from events such as childbirth and menopause
• GPPPD is an umbrella term that covers all types of genital pain in females

New diagnosis that replaces previous diagnoses of the DSM-4

• Vulvodynia: vulvar pain, pelvic pain
• Vaginismus: avoidance, tense of muscles, fear of pain

Question 86

Vulvodynia

Answer 86

• Vulvar pain of at least 3 months duration without a clear identifiable cause
• Affects 10-28% of women in the general population
• Significant, negative impact on sexuality, mood, and quality of life
• Types include: provoked vestibulodynia (pain occurs with contact to the vestibular area), generalized unprovoked vulvodynia (involves the whole vulvar area, and can pain can occur with no contact), clitorodynia
• Name of diagnosis identified area of pain, the nature of the pain (provoked vs. unprovoked), and onset (primary = whole life, secondary = developed as a result of an event)
• Affects ~8% of women and can have significant negative impacts on function
• Many subtypes including: provoked vestibulodynia (PVD), and generalized vulvodynia (GVD)

Question 87

Provoked Vestibulodynia (PVD)

Answer 87

• most common type of vulvodynia
• Pain during activities vaginal penetration (sexual, and nonsexual) –> provoked, and not constant pain
• Localized to the vulvar vestibule –> area surrounding vaginal opening
• Pain can also be deeper in the vaginal canal, which manifests as deep dyspareunia
• *Diagnosis:**
• tell someone about the pain
• cotton-swab test
• rule out other causes like infection, inflammation, etc
• *Risk Factors:**
• history of repeated yeast infections
• hormones –> starting hormonal contraceptives at early age (around 13)
• history of abuse and mood disorders
• other pain conditions (pain conditions clump together)
• vuvlar hypersensitivity
• *Treatment:**
• Therapy targeting sexuality
• Pelvic floor physiotherapy
• Surgical: involves removing a minimal amount of the vestibular tissue around the vaginal opening g that removes all the hypersensitive pain receptors (2-3 mm) –> works for many people and usually recommended after first two options
• Medical: creams, meds, etc. don’t really work

Question 88

Generalized Vulvodynia

Answer 88

• Pain is constant, or almost always constant (sexual and nonsexual)
• Usually a burning/stinging quality to pain
• Affects entire/large part of the vulvar area –> can be hemivulvodynia that affects the only the left or right side, or less commonly, the top/bottom
• Prevalence rate of 5%
• *Risk Factors:**
• Older age –> primarily occurs in those older than 35, maybe due to nerve damage over time
• Pelvic injury/surgery
• Other pain conditions
• Psychological factors –> depression, anxiety, mood disorders
• *Treatment:**
• Therapy targeting pain and sexuality
• Pelvic floor physiotherapy
• Surgical: not really an option bc there is nothing to take out as its pain from the nerves
• Medical: prescribe low does tricyclic (antidepressant) to suppress pain response (neuropathic pain)

Question 89

Vaginismus

Answer 89

• Specific phobia related to vaginal penetration, characterized by increased muscle tension and behavioural avoidance –> not its own diagnosis in the DSM-5 anymore
• Often overlaps w PVD –> it either causes PVD or its comorbid
• *Definition of Specific Phobia:**
• Marked fear/ anxiety about a specific object or situation
• Object/ situation always provokes fear/ anxiety
• Object/ situation is actively avoided or endured with intense fear/ anxiety
• Fear/anxiety is out of proportion to the actual danger posed by object/ situation
• 6+ months, causes clinically significant distress
• People w vaginismus have marked fear/anxiety which is the most common reason for avoidance of sexual activities, and significant pain related to penetrative activities
• They express high levels of distress in penetrative activities
• Behavioural avoidance: never go to gyne exam, never have penetrative intercourse
• Fear is out of proportion (scared they will be torn apart)
• *Risk Factors:**
• Negative sexual attitudes
• Lack of sexual education
• History of abuse or mood disorders
• Pelvic floor issues
• *Treatment:**
• Psychotherapy targeting pain, fear, avoidance, anxiety, sexuality
• Pelvic floor physiotherapy if it is tolerated
• Not many medical interventions and not a lot of research –> sometimes antianxieties or vaginal suppositories

Question 90

Penile, Testicular, and Pelvic Pain

Answer 90

• Pain affecting penises/ testicles and pelvises
• Urologic chronic pelvic pain syndrome (UCPPS)
• Chronic (nonbacterial prostatitis)
• Chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS)
• Impacts 6% of the population
• Normally for people who have pelvic/ penis/testicular pain without evidence of UTI or other potential causes
• Have pain in perineum, testicles, penis, public/ bladder area, ejaculatory pain
• 3 or more months
• Symptoms may wax and wane
• Cause is unknown –> but are probably due to vulnerabilities/RF that pile on top of each other
• Pelvic floor dysfunction, nerves, stress (immune system), hormones
• Treatment can include medication (alpha blockers, antibiotics), and pelvic floor physiotherapy

Question 91

Causes of Sexual Problems: Intrapsychic Factors

Answer 91

• Psychological factors begin to develop in early childhood, based on interactions with and observations of family members
• Both the parents relationship with each other and their relationship with their children help to lay the foundations for warm and loving attachments or difficulties with being closed in adulthood
• E.g. the way the parent bathes their children, and whether/how they touch them in general –> Impact children’s feelings about their bodies, body image, and broader sense of self
• Parents emotional and sexual relationship with each other also transmits whether intimacy a safe and to be sought after or something fraught with danger and to be approached warily
• Silence and sense of taboo around sexuality is acquired early and wordlessly in may often make it difficult to communicate freely in adulthood about one’s sexual desires
• Discomfort may be identified if one is sexually abused in childhood and further complicated for individuals with disabilities
• Low self-esteem, fear of being inadequate, or fear of pregnancy and STI’s can make it harder to anticipate and enjoy actual experiences
• Cultural expectations that everyone should be sexually active in skillful and find sex easy creates foundations for performance anxiety
• TSS does not allow for flexibility and creativity which may be a central for one’s sexual expression

Question 92

Causes of Sexual Problems: Interpersonal/Relational Factors

Answer 92

• Sometimes the appearance of sexual problems may actually be a symptom of underlying difficulties in a relationship including inadequate communication
• Children who observe parents working through conflicts in a productive manner will learn how to manage conflict constructively in adult relationships
• Children who observed parents engaging in unproductive conflict resolution habits will not know how to argue constructively
• Those with poor conflict resolution skills will be unable to express feelings and may suppress them –> eventually they will be unable to express/experience passion in sexual relationship
• Inability to resolve fights can also contribute to, and exacerbate other relational causes of sexual problems leading to various kinds of power struggles
• Other interpersonal sources of sexual difficulties include NCNM, jealousy, and distrust as well as being disappointed in sex and fear of being disappointed or hurt again

Question 93

Causes of Sexual Problems: Cultural/Psychosocial Factors (types of teaching/education)

Answer 93

• *Religious Teachings:**
• Most religious traditions promote certain sexual values and advertise their followers on what sexual behaviors are and are not permissible
• Over recent years influence of Christian churches has declined, with fewer adults self-defining as practicing Christians
• A variety of non-Christian religions have also become established in Canada
• *Family-Based Teaching:**
• Implicit lessons include the fact that there is little open nudity in most households suggesting that nudity should be avoided or hidden away
• Explicit lessons tend to be aimed at teaching children what not to do without any positive messages about how to express one’s sexuality in a healthy way
• The use of negative language and admonitions about touching one’s own genitals tend to leave a strong impression on children that the genitals are forbidden zones –> leading individuals to believe sex is dirty
• *School-Based Sex Education:**
• As formal sexual health education in Canada is provincially regulated, the content, amount, and timing varies with hardly any uniformity across the boards
• Overall sex ed in Canada seems to convey the basics of reproductive biology and how to avoid STI’s, with little to no mention of sexual feelings, desire, or pleasure
• The silence surrounding these topics suggest to students that their feelings connected to sex in their desires for sexual pleasure are taboo, meaning that students are far less prepared to deal with the complexities of adult sexuality
• *Sources of Misinformation:**
• Many myths have a direct bearing on the development of sexual dysfunctions and are frequently reinforced in popular media
• sexually explicit videos can be particularly misleading source of misinformation because they reinforce unattainable body image ideals and unrealistic performance expectations, making viewers feel defective by comparison

Question 94

Causes of Sexual Problems: Organic Factors (Low Desire)

Answer 94

• CVD and treatments for it can affect sexual arousal and response adversely –> anything that can restrict blood flow to the heart can also impair blood flow to the genitals
• *Role of Hormones:**
• Hypothyroidism and anemia both contribute to low desire, but should be ruled out when an individual reports high levels of fatigue in association w low desire
• After giving birth, low desire can be due to low hemoglobin levels, and elevated prolactin (if breastfeeding) which can lead to vaginal dryness and thus reduce desire –> iron supplements and lubrication
• *Neurological Disorders, and CNS Injuries:**
• Disorders, diseases, and injuries that cause damage to the CNS can affect sensation and/or movement and thus have an adverse impact on sexual functioning or response
• Diabetes can lead to peripheral neuropathy, which can affect sexual functioning by reducing blood flow to the genital and eventually causing deterioration in nerve function
• It can also cause ED and difficulties in lubrication and sensation in women
• *Drug-Rleated Causes of Sexual Dysfunctions:**
• Masters and Johnson wrote that 90% of the causes of sexual dysfunction were psychogenic and only 10% were organic
• All manner of drugs (including prescription, OTC, and recreational drugs) can affect sexual functioning, response, and desire
• the most common medications that have an adverse impact on sexuality are those used to treat CVD, arthritis, high cholesterol and cancer, and most psychiatric drugs (SSRIs, SNRIs)
• Some narcotics including depressants and stimulants are used for their alleged aphrodisiac properties, but true aphrodisiacs do not exist
• Binge drinking can lead to ED referred to as “whiskey dick”, and it also impairs judgment and has been correlated with sexual assault and failure to practice safe sex
• Hormonal Contraceptives:*
• Depo-provera has been linked with low sexual desire –> may add to low desire in new mothers
• Cyproterone acetate which is used to treat cystic acne (aka Diane and Ginette), has a powerful impact on the entire endocrine system and interferes with ovulation and can cause a reduction in sexual desire

Question 95

Causes of Sexual Problems: Quality of Sexual/Erotic Contact

Answer 95

• Sometimes there are no mechanical failures, but the quality of the sex makes all the difference in whether the partner feels aroused or not
• The DSM notes that it’s important to consider the adequacy of sexual stimulation and diagnosing sexual disorders, but does not provide guidance as to what counts as adequate
• most people are reluctant to tell their partners precisely how they like to be stimulated and are even more embarrassed to show them, and many patients are uncomfortable asking these types of questions

Question 96

Hypoactive Sexual Desire Disorder (HSDD)

Answer 96

• too low desire was first introduced as inhibited sexual desire (ISD) in DSM-3 and was soon remaned as HSDD
• persistent or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desires for sexual activity
• desire refers to subjective experience of feeling sexual interest and being sexually open
• In the DSM-4 HSDD was commonly thought of as low desire or libido, and sexual aversion was an intense negative or fearful response to a specific aspect of sexual interaction

Question 97

Sexual Interest/Arousal Disorder (SIAD) (6 characteristics)

Answer 97

Characterized by at least 3 of the following: absent/reduced

• interest in sexual activity
• Sexual/erotic thoughts or fantasies
• Sexual excitement/ pleasure during sexual activity in almost all or all (75–100%) sexual encounters
• Sexual interest/arousal in response to any internal or external sexual/erotic cues
• Genital/nongenital sensations during sexual activity (75–100% of encounters)
• No/reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate sexual activity
• *RF:**
• Negative sexual cognitions/attitudes –> usually from family of origin
• Past/current history of psychiatric conditions
• Medications (esp for mood disorders)
• Medical conditions
• Partner and relationship factors (discrepency)
• woman is feeling subjectively aroused but not lubricating, some factors may be the reduction of estrogen when a woman is breastfeeding or post-menopausal, the use of antihistamines and decongestants for allergies, some diuretics and oral contraceptives, and chemotherapy and radiation

Options:

• addyi?

Question 98

Possible Causes of Desire and Arousal Problems in Men and Women

Answer 98

• Factors can include a lack of attraction to one’s partner, a recent argument that is yet to be resolved, a history of sexual assault, on-going fatigue and stress, and fear of pregnancy or STI’s
• Sometimes individuals do not become aroused because the quality of the sexual contact itself is not particularly stimulating or erotic for them
• Cultural values that discourage open expression of sexual wishes can prevent individuals from asking for what they want, and certain drugs can interfere with sexual desire and arousal
• HSDD has been linked w decreased testosterone levels, and biological factors such as aging, medical conditions and psychotropic and other medications
• Mental health problems and the presence of their sexual dysfunctions can also lead to low arousal
• often associated with many other problems –> can you really diagnose a person w low desire if there are other issues causing the problem

Question 99

Sexual Desire Discrepancy

Answer 99

• sexual desire difficulties come to be perceived in the context of relationships
• Most common problem is sexual desire discrepancy; this difficulty arises when one partner’s desire for sex is noticeably greater than the other –> sometimes the partner may not have any problem but there is just a large discrepancy
• domino effect of many factors
• Often times low sexual desire can come from having complications from a routine, and once the couple has decided the woman has a problem of low desire they may try to overcome or work around the problem rather than confronting the root issue of poor conflict resolution
• Pure desire disorders in which the root or essence of the problem is a lack of sexual desire does exist but seem to be very rare and represent only a small fraction of desire discrepancy problems experienced by couples –> diagnosis of desire disorder in its true form is very rare

Question 100

Why are arousal and desire/interest disorders combined in women?

Answer 100

• Research has suggested that women perceive overlap in the ideas of sexual desire and arousal, and as a result the categories of female sexual arousal disorder and HSDD are collapsed into one category called sexual interest arousal disorder (SIAD)
• arousal refers to the physiological component, and subjective experience

Combined bc:

• past reliance on thoughts/fantasies –> women fantasize sexually less than men, so a diagnosis based on thoughts and fantasies meant that women were being misdiagnosed
• issues of spontaneous vs responsive desire –> women have more responsive desire and men have more spontaenous desire, but the previous diagnosis would pathologize this
• lubrication issues can be overcome with lube, saliva, etc, so its own diagnosis didnt really make sense
• less pathologizing of women and their normative experiences

Question 101

Too Much Arousal as an Issue?

Answer 101

• High desire is not listed as a disorder in the DSM
• The notion of sex as something that one can be addicted to does not fit with the thinking of most specialist and sex therapy or addiction treatment
• Was proposed that hypersexual disorder be introduced in the DSM-5 but suggested that most patients will be men and noted there is little research on hypersexuality in woman
• DSM is deficiency based model and doesn’t address ppl on the higher end of the spectrum
• Desire doesn’t always align w behaviour so no assumptions should be made –> can have a lot of sex w low desire or not a lot of sex but have a lot of desire

Question 102

Erectile Disorder

Answer 102

• Erectile issues are very common: drunk, high, pressured, tired, stressed, not interested, don’t know partner, distracted, not feeling well

At least one of the following on all/almost all (75-100%) occasions of sexual activity:

• Significant difficulty obtaining an erection
• Significant difficulty maintaining an erection
• Significant decrease in erectile rigidity
• One can still have pleasure with a flaccid/ not fully erect penis
• *Causes/ RF:**
• Anything that might interfere with blood flow to the penis or enjoyment of tactile stimulation can impede erection
• Organic causes include CVD, diabetes, and the side effects of many medications that affect the CV system, and SSRIs
• Age, esp 50+ years
• past/current history of psychiatric conditions
• medications and medical conditions
• partner and relationship factors
• lifestyle (exercise, smoking)

Options- PDE-5 Inhibitor, sex therapy, talk to partner about type of stimulation needed/wanted

Question 103

Orgasms in General

Answer 103

• Orgasms occur on a continuum from intense pleasure to mediocre
• Media portrays orgasms to be very pleasurable all the time –> one might have a moderately pleasurable orgasm but be dissatisfied due to what they expect
• Coital- not uncommon that people don’t orgasm with penetrative sex (esp penile-vaginal)
• Multiple- could be rare or even impossible that a person have multiple orgasms in one interaction
• Simultaneous- might not be a reasonable goal to have a simultaneous orgasm w partner
• Males have orgasms more frequently than females

Question 104

Female Orgasmic Disorder

Answer 104

The presence of at least one of the following symptoms experienced in 75–100% of sexual encounters:

• marked delay in marked infrequency of, or absence of orgasm
• marked reduced intensity of orgasmic sensations
• OD is also conceptualized as a result of hypofunctional excitation, hyperfunctional inhibition, or both
• Primary anorgasmia is often related to a woman’s lack of knowledge of her own body and sexual response (pre-orgasmia?)
• Secondary anorgasmia is generally more complex in origin and in treatment
• *Causes/RF:**
• The frequent cause of primary anorgasmia is a woman’s lack of knowledge about her own body and sexuality
• Secondary anorgasmia is commonly caused by pharmacological side effects –> in particular SSRI’s and antipsychotics are well known to disrupt orgasm
• Secondary may also be linked to psychological or interpersonal difficulties affecting the woman in her relationship
• RF: psychological factors (e.g. anxiety, fatigue, mental health), medications (esp for mood disorders), mood disorders, partner and relationship factors, sociocultural factors

Options- psychoeduction, self-exploration, making sure no other physical issues at hand

Question 105

Male Orgasmic Disorder: Delayed Ejaculation (DE)

Answer 105

The DSM-5 classifies it as the presence of the following symptoms experienced on all/almost all (75-100%) of occasions of partnered sexual activity and without the individual desiring delay

• Significant delay in ejaculation
• Significant infrequency or absence of ejaculation
• The individual may be forced to delay bc of partner or whatever the situation may be but it’s not desirable (doesn’t include edging)
• Not the same as retrograde ejaculation where the semen doesn’t exit the penis but flips back into the bladder –> test for semen in the urine
• More commonly men who are diagnosed are able to ejaculate alone, but have difficulty with a partner, particularly during vaginal or anal intercourse
• *Causes/RF:**
• A major cause of secondary (recent onset) DE is the use of psychotrophic drugs, especially antidepressants and antipsychotics
• In cases where a man has never been able to orgasm, cause tends to be organic
• Posited that the issue is with the notion that the mere presence of an erection must signify that a man wants to engage in intercourse, which leads couples to engage in sex based on minimal cues of arousal –> when couples wait for arousal to become intense it is much less likely that sexual dysfunctions will arise
• the use of erectogenic drugs may also reinforce the conflation of performance and arousal/pleasure
• RF: age-related factors, psychological factors, medications, partner/relationship factors, autosexual orientation (preferring solo activity), idiosyncratic (particular, quirky) masturbation habits

Options- pay more attention during sex to arousal, understand that erection doesn’t have to mean sex, withdrawal from certain meds

Question 106

Male Orgasmic Disorder: Premature Ejaculation (PE)

Answer 106

• Rapid ejaculation is the most common sexual dysfunction affecting men
• Ejaculation issues are very common –> younger ppl tend to ejaculate quicker, new sexual experiences increases (novelty), frequency (those who haven’t in a while might ejaculate faster than they expect)
• Average time for ejaculated from vaginal penetration is 3-8 mins

An individual is diagnosed if they ejaculate within 60 seconds of penetration (and before the individual wishes) during partnered sexual activity 75% of the time for a period of six months or longer, and if it causes distress for the individual experiencing the symptoms

• The 1 min is not a hard and fast rule for diagnosis
• If the person ejaculates fast during masturbation and they are not distressed ab it, then it is not diagnosable; usually during partnered activity shame is experienced which is what causes the distress
• DSM says vaginal penetration, but this extends to those having issues during things like oral sex, MSM
• *Causes/ RFs:**
• Some have suggested that this difficulty results from anxiety, lack of control, genetic factors, or penile hypersensitivity others have hypothesize that the problem was created by the adolescent hurrying through solo or partnered sex to avoid being caught by his parents
• RF: anxiety disorders, especially social anxiety, genetics (penile hypersensitivity?), learning and environmental factors (might be conditioned to finished faster bc cultures/family is not accepting of it)

Question 107

Other Sexual Dysfunctions

Answer 107

• ‘normal’ when subjective feelings of arousal are concordant with genital feelings of arousal
• When subjective feelings of arousal are high, but genital arousal is low –> some cases of SIAD, and ED
• When subjective feelings of arousal are low, but genital arousal is high –> PGAD (not the same as priapism which is a sustained erection when an individual is not aroused; can be very dangerous as it can damage the vascular system of the penis)

Question 108

Other Sexual Dysfunctions: Persistent Genital Arousal Disorder (PGAD)

Answer 108

• Symptoms of physiological sexual arousal persistent for an extended period of time and do not subside completely on their own
• The symptoms do not resolve with ordinary orgasmic experience and may require multiple orgasms over days to remit –> not just unwanted/undesirable but distressing and disturbing
• The symptoms are usually unrelated to any subjective sense of sexual excitement/desire
• The symptoms can be triggered by sexual/non-sexual stimuli, or by nothing apparent
• The symptoms are unwanted and feel intrusive, and may lead to distress
• PGAD in women, Priapism in men

Question 109

Other Sexual Dysfunctions: Hypersexuality (Sex Addiction)

Answer 109

• Subjective feelings and genital feelings are in concordance, there’s just too much arousal

Can involve:

• Obsessive pursuit of casual sex
• Excessive porn use
• Compulsive masturbation
• Feelings of loss of control
• Risky behaviours –> spending all money, losing job, harming other ppl emotionally
• Used to cope with negative mood states –> used as an escape to not have to think of anything negative
• Functional impairment/ distress
• Not the same as PGAD bc there is mind and body concordance

Question 110

Other Sexual Dysfunctions: Post Orgasmic Illness Sydome (POIS)

Answer 110

• Muscle pain, fatigue, mood difficulties, and concentration for up to 2 weeks post orgasm (usually for about a week)
• Might be an allergic response to a physiologic response during orgasm

Question 111

Other Sexual Dysfunctions: Female Orgasmic Disorder (premature orgasm?)

Answer 111

• Females can potentially experience orgasms too quickly and feel distress
• They might either orgasm before 1 min, or not at all and this can be distressing

Question 112

Dyspareunia in Men

Answer 112

• A multitude of diseases can cause pain and erection or during and after ejaculation, including STI’s, benign or cancerous diseases of the prostate and testes, and Peyronie’s disease
• Treatment options in men generally focus on treating the underlying disease and is usually conducted by urologists

Question 113

History of Sex Therapy

Answer 113

• Modern history of treatment for sexual dysfunctions begins w Masters and Johnson with their classic book Human Sexual Inadequacy
• Before their treatment paradigm, sexual problems were the province of clergymen, general psychotherapists, or marriage counsellors
• Masters believed that sexual functioning needed to be brought out of the domain of philosophy, religion and depth psychotherapy and should be the subject of scientific inquiry
• This sentiment paved the way for the development of the treatment of sexual difficulties as a scientific endeavour and reified the belief that sex was best understood as a primarily physical phenomenon
• The treatment model developed by Masters and Johnson consisted of brief, intensive, behavioural oriented sex therapy
• The goal of treatment was to eliminate obstacles so that ‘normal’ sexual response can be restored
• Observed that couples with problems avoided touch entirely, and that much of their fears were associated w performance anxiety –> spectatoring refers to the monitoring of one’s functioning

Question 114

Sensate Focus

Answer 114

• Cornerstone of sex therapy and basic step for treating all sexual issues –> very adaptable
• Expands sexual repertoire, which is critical, its akin to starting over
• Involves focusing on sensations (sensual mindfulness) –> focusing on what is pleasurable/ painful when an individual touches themselves or is being touched, and on being present
• First phase (non-genital sensate focus) involves touching for 20 mins (no breast, genital, or anal contact) allowing couples to reconnect physically w the expectation of sex which circumvents performance anxiety –> a form of starting over with no distractions or expectations
• Second phase (genital sensate focus) involves touching each other from head to toe with no aim other than enjoying the pleasure of touch. Can consist of a variety of different exercises specific to a given difficulty, but in most cases the couple is instructed to engage in nondemand genital touching
• The third phase (penetration without movement) done after already setting up a sensual mood. objective at this point is to experience heightened sexual pleasure and target the sexual symptom for elimination without triggering the anxiety and spectating engendered by the expectation of intercourse
• ED: can help to reduce performance anxiety, catastrophasizing by helping individual understand that erections wax and wane –> being mindful of the sensations without the performance aspect
• Fourth phase is penetration with movement

Question 115

Sex Therapy in the New Millenia

Answer 115

• The focus of eliminating sexual symptoms as obstacles to normative sexual functioning has remained a feature of the predominant treatment models
• It has been easy to overlook the conflating of symptoms with underlying problems especially since the success of PDE-5 inhibitors
• Sex therapy is fragmented –> much of the treatment of sexual difficulties is now provided by individuals with minimal training in sexuality or in individual relationship therapy
• Since mid 90s, increasing medicalization of the field has meant less emphasis on the complexity of sexual difficulties
• Reduction in hours devoted to med school training in sexual matters has left physicians poorly equipped to deal w sexual difficulties
• Health care providers also fail to recognize the potential of ppl with disabilities to enjoy intimacy and sexuality within their relationships
• Very important to seek out a clinician w expertise in both human sexuality and psychotherapy

Question 116

Types of Treatment for Sexual Dysfunctions

Answer 116

• Can be medical or non-medical
• It is ideal to be assessed by a team of professionals with different specialties
• A lot of times it is just a medical professional, which is sometimes okay, and in other cases not ideal

Question 117

Non-Medical Treatment: Sex Therapy (Psychotherapy)

Answer 117

• There are many inaccurate beliefs such as the therapist will be sexual with the individual, or make direct orders (like have a threesome) for the individual
• Sexual surrogacy is not the same as sex therapy and is different from ‘sex work’
• In the 60s and 70s, a sexual surrogate as a trained person who worked w a therapist and engaged sexually w a client
• Help a person in therapy and reach goals with no other personal relationship to the patient
• It is based on the client’s values, beliefs, and goals –> as long as they are reasonable rational and consensual, even if they don’t necessarily align w the therapists’ goals
• Sex therapy is talk therapy that addresses sexual issues and concerns
• The therapist has lots of knowledge, expertise, and comfort in the area of sexuality (specifically trained in the area)
• The therapist also needs to be well versed in other areas of psychology bc it is likely that the individual will come in w many other psychological comorbidities
• Some sex therapists also provide couples therapy
• Sex therapy is based on the PLISSIT model (1976)

Question 118

PLISSIT MODEL

Answer 118

• *P**- permission
• *LI**- limited information
• *SS**- specific suggestions
• *IT**- intensive therapy
• Gets deeper as you go down, but it is not always linear as if the individual has a lot of other serious issues, those neeed to be worked on first

Question 119

PLISSIT Model: Permission (P)

Answer 119

• Can be very in depth or very superficial depending on the client and context
• In a sex clinic, permission is somewhat brushed over as you assume that the client is comfortable talking about sex, but in a medical setting, a doctor might ask “can I ask some questions about your sexuality?”
• Reassurance- reassure that some things they are doing might be good for them, create a judgment free environment
• • Satisfying and consensual*
• Appreciate own unique patterns- take time to reassure the individual that their uniqueness is good and they will find someone for them
• Permission to engage, or not- e.g. for pain during penetration the therapist will encourage client not to engage in very painful experiences that can cause distress, and will provide permission to do activity that isn’t painful (at least in the short-term)

Question 120

PLISSIT Model: Limited Information (LI)

Answer 120

• Educate- don’t need to go through all of sex ed, but just what is relevant to the client
• Dispel myths that could be internalized and challenging unreasonable thoughts to help reduce anxiety
• Takes a multimodal approach

Question 121

PLISSIT Model: Specific Suggestions (SS) –> ED and PE techniques

Answer 121

• Based on a clients goals
• Goal is to reduce anxiety and enhance communication
• Teach new arousal-enhancing behaviours (expand repertoire) –> break loops that are associated with negative outcomes and recreate sexual experiences
• sensate focus, communcation, pelvic floor muscle therapy
• *Progressive Awareness Exercise:**
• A lot of people (girls esp) are unaware of what does it for them
• Genital stimulation at a young age = more awareness when older
• Aim is to get the individual to be okay or at least neutral with their genitals –> a lot of ppl have internalized shame
• *Start-Stop Technique:**
• Used to treat ED or PE
• For ED, penis is stimulated until erection and then stopped, and then erection subsides and then repeat
• This proves that a lost erection can be regained (control over erection), and they don’t need to eagerly act on the first erection that they get
• For PE, the threshold at which point it is almost impossible not to ejaculate is figured out and individual stimulates themself until this point, stops, erection subsides, repeat
• This is done until they have some control over when to ejaculate, and there is a lot of failure at the beginning

Squeeze Technique –> Push firmly right near head of penis right at threshold to cause the nerve responsible for ejaculation to pause and inhibit the ejaculatory reflex

• *Other Tips for PE:**
• Ejaculate more frequently
• Return to sex therapy
• Communicate with partner
• Change positions
• Consider alternatives to penetrative activities
• *Other Tips for ED:**
• Education
• Reducing performance anxiety and spectating
• Sensate focus
• Break down myths of male sexuality –> all physical contact leads to sex, a male always wants and is ready for sex, in sex only performance counts, sex = intercourse, sex = spontaneous

Question 122

PLISSIT Model: Intensive Therapy (IT)

Answer 122

• When issue cannot be addressed by sex therapy alone

Question 123

Non-medical Treatment: Pelvic Floor Physiotherapy

Answer 123

• Weighed more to female bodies
• Restore, maintain, and maximize strength, function, movement, and overall well-being
• Pelvic floor therapists are pelvic floor experts –> they receive extra training in the pelvic floor, as the pelvic floor musculature is very complicated
• It can be useful for tight pelvic floor muscles, loose pelvic floor muscles, other issues such as incontinence, vaginismus, pelvic pain
• Treatment for those with GPPPD (vulvodynia, vaginismus), for those with ED and maybe PE, actually good for most ppl and very hands-on
• Techniques for GPPPD:
  
  • Manual techniques- massage, trigger points release, stretching, etc., treat pelvic tissue abnormalities and restrictions
  • Vaginal dilation exercises- stretch and desensitize vaginal opening, improve muscle control, reduce fear/ anxiety related to penetration (vaginismus)
  • Biofeedback- aids in normalizing muscle activity and improving control of PFMs; a range of devices are used –> sensors of whats being tensed and what isnt to educate about it

Question 124

Pharmacological Treatments: Oral Medication for ED

Answer 124

• Viagra was the first oral medication (came to Canada in 1999), followed by Cialis (weekend drug) and Levitra
• ED used to be the only sexual dysfunction as it is easy to test/observe/study
• The first line treatment for ED is medical
• Oral medications allowed for discussion around sexual dysfunction, and helped to reduce stigma
• In more recent years, there has been a rebound in other medical treatments as Viagra doesn’t work for everyone and there might be other underlying issues –> only 50 acc fill out prescription, and few refill
• Viagra for ED:
  
  • Was originally developed for hypertension/ heart disease
  • Blocks PDE-5 which allows the vascular response of an erection to occur –> there still needs to be stimulation, i.e., no spontaneous erection
  • Takes ~30 mins to work, but large/fatty meals will increase absorption time and delay onset of action –> grapefruit juice (flavonoids) reduces absorption of Viagra
  • Side effects: facial flushing, headache, dizziness, altered vision (bluish tinge), diarrhea, rashes, and in rare cases, sudden loss of vision or hearing, priapism, but nothing fatal
  • Contraindication: nitrates –> can cause fatal hypotension
  • Viagra doesn’t work with SIAD, and doesn’t solve underlying issues such as couple problems

Question 125

Pharmacological Treatments: Intracaveronosal Injections for ED

Answer 125

• Vasodilators injected into penis (e.g. papaverine, phentolamine)
• Relaxes smooth muscle tissue in the penis –> acts only peripherally and locally
• No sexual stimulation is needed
• A very fine needle is injected into one side of the cavernous bodies (switch sides and spot every time), about 1 inch from base (to ensure the erection is firm from tip to base) –> can be a hurdle for those sensitive to needles
• It is virtually painless, takes 4-10 mins to work, and lasts 1-2 hours
• Side effects: potential numbness in glans penis, tissue damage if needle is placed in same spot, priapism, no real long-term effects or fatalities
• Need to decide it’s worth the firm erection if one is apprehensive about injections

Question 126

Pharmacological Treatments: Medicated Urethral System for Erection (MUSE)

Answer 126

• Suppository/pellet used as an alternative to injections (oral meds –> injection –> MUSE)
• Pushed into urethra with an applicator, and then penis massaged to spread medication around
• Takes 5-10 mins for erections to occur, and erections last 30-60 mins
• Only insert one pill at a time –> 2 pills within 24h and not at same time
• Reliability: sometimes can cause a top heavy erection (not firm at base), and only works for 30% of ppl who use it
• Issues: can cause vaginal, anal, oral irritation/itching/burning for recipient (need to use condom), do not use w pregnant women –> both ejaculate and medication comes out of urethra
• Side effects: mild discomfort when applying it, high dose med (more so than injection) and can cause ache and pain, priapism

Question 127

Pharmacological Treatments: SSRIs for PE

Answer 127

• Take advantage of a side effect to treat those w PE
• Not approved by FDA for this purpose –> off-label use
• Only referred to for severe cases
• Start with the lowest dose
• Side effects: cognitive confusion, tiredness, dry mouth, dizziness

Question 128

Pharmacological Treatments: Oral Medication for Low Desire (Addyi, The little pink pill)

Answer 128

• Might even the narrative that men’s issues are simple and women need to talk through their problems
• Non-hormonal multifunctional serotonin agonist antagonist (MSAA)
• Works on dopamine, NE, and serotonin –> balance all neurotransmitters and desire?
• Daily medication
• Side effects: sleepiness, insomnia, dizziness, fatigue, dry mouth, vertigo, anxiety
• Don’t take with alcohol
• In three 24-week clinical trials with 2400+ females with HSDD, there was an increased number of satisfying sexual events by 0.5-1/month versus the placebo
  
  • ~10% more of those on Addyi reported meaningful improvements in satisfying sexual events, desire, distress
• In another 2016 study, 0.5 SSEs/month, but lots of side effects
• Not female Viagra bc it has central effects, and not local, it is taken every day and not as needed, and it targets desire and not arousal
• Other barriers:
  
  • Sales are low- sales never really took off
  • Cost is high –> 800 USD/month
  • Barriers –> need to find a pharmacy with a doctor that has a specific licence to distribute it (access is difficult), can’t drink alcohol with it because it can cause fatal hypotension
  • What exactly is an SSE –> not an empirical measurement, different for each person, and hard to operationally define
  • Who will this drug help more? –> might just be for the partner because they are the one who want more sex

Question 129

Pharmacological Treatments: Injectable Medication for Low Desire (Vyleesi (bremelanotide injection))

Answer 129

• Subcutaneous injection that acts as a melacortin (melanin) receptor agonist (exact mechanism unknown)
• Self-administered as needed (thigh, abdomen) 45 mins – 1 hours before anticipate sexual activity
• Tested in premenopausal women with acquired/secondary HSDD –> haven’t been trialed on other demographics, and increased desire in rats
• Duration of effects unknown
• Co​st: 900 USD per injection
• Effectiveness: increased desire, less distress, increased satisfaction and more arousal reported (seemingly more convincing than Addyi?); actual number of SSE didn’t change but each encounter was more arousing
• Side effects: nausea, hyperpigmentation, redness/irritation at injection site, dizziness, headache, and dysesthesia (unpleasant sensations)

Question 130

Mechanical Treatment: Vacuum Erection Pumps

Answer 130

• Vacuum chamber fit over flaccid penis flush with the base of the penis
• Blood is drawn into the penis through suction
• The constriction band is kept on, keeping the blood in the penis, but the chamber is taken off
• Constriction band can be safely kept on for 30 mins, but tissue damage can occur if kept on too ling
• Cost: $300-$600 depending on brand and type, but automatic one tends to work faster and is more expensive
• Effectiveness: 50-80% of users are satisfied
• Contraindications: may not work as well on those on blood thinners, do not use if you have blood disorder, or SCD
• Side Effects: red dots of blood, a little numb/cold/blue but not common, ejaculate feels stuck?
• Drawbacks: can be awkward, may feel like an unnatural erection (some ppl have issues with it not being spontaneous), issues incorporating it into sexual script

Question 131

Surgical Treatment: Semi-rigid Penile Prostheses

Answer 131

• Rod inserted into corpora cavernosa
• The individual bends penis from flaccid to erect state, but the penis is always going to be semi-erect
• Only the angle of the penis can be changed, not the length
• The rod doesn’t span the entire length of the penis (partially so it doesn’t pop out of tip)

Question 132

Surgical Treatment: Inflatable Penile Prostheses (3-piece system)

Answer 132

• The inflatable cylinder is placed into the cavernosa, fluid reservoir put into abdomen, and pump bulb and release valve placed into scrotum
• Squeeze pump in the scrotum, fluid will till the cylinder and penis will be erect
• Press on release valve and fluid will flow back into the reservoir and penis will be flaccid
• 2-piece system is similar but the fluid reservoir is at the end of the cylinder in the penis

Question 133

Outcomes of Penile Prostheses

Answer 133

• Users can have erections as long as they want, and both types have very high satisfaction (with inflatable being more satisfactory)
• Inflatable tend to be more natural acting/ feeling
• There can be issues with the fancy components of inflatable, and they require individual to be dextrous/have good coordination
• The pump is replaced every 5 or so years, and semi-rigid lasts more towards the 10-year mark
• Last resort –> both cause permanent damage to the corpora cavernosa and there will no longer be any chance of natural erection if removed; used on older people and those with serious contraindications/adverse effects with other meds
• Side Effects: few week recovery post-op, altered sensation during erection and ejaculation, some people are disappointed (likely due to their expectations)
• Shaft and base = good erection, glands = a little less erect bc implant cant extend into glans –> no corpora cavernosa, and don’t want to interfere w urethra
• Slightly smaller penis when erect bc of standardized length of rod
• Paying out of pocket bc it’s an elective surgery

Question 134

Surgical Treatment: Vulvar Vestibulectomy for PVD:

Answer 134

• 2 mL of tissues from vulvar opening is removed
• Minor days surgery, and spinal anesthesia used
• High success rates –> 50-100%
• No penetration 6-8 weeks after surgery, and some pain during healing
• Decrease in pain, but not significantly more sex post op (maybe not a bad thing bc instead of penetrative sex other methods are used –> repertoire expanded)
• Issues: vulvar enhancement means vulva may look different; some people might not feel much sensation at all post-op
• Not usually a first-line treatment, but sometimes recommended as such –> surgery covered by insurance but other types of treatment aren’t