Sexual dysfunctions
43% women, 31% men in US suffer from sexual
problems (age 18-59)
 For women, problems decrease with age, except
problems of lubrication
 For men, problems with desire and erection increase
with age

 Men 50-59 were 3x as likely to report these as men 18-29
Pre and post-marital (divorced, separated, widowed) at
increased risk for problems
 High educational attainment is negatively associated
with sex problems for both men and women
 Falling household income is assoc with increase in all
sexual dysfunctions for women, but only erectile
dysfunction for men

4 categories
Sexual desire disorders
 Sexual arousal disorders
 Orgasmic disorders
 Sexual pain disorders
 All must be recurrent

Sexual desire disorders

Hypoactive Sexual Desire Disorder—little or no
interest in sex, absence of fantasies
 More common among women
 Hard to define low desire, difficult to treat
successfully
 Often brought in by other member in couple
 Causes—bio—testosterone deficiencies, thyroid,
diabetes, medication for hypertension, CA, heart,
and others
 Psych—anxiety, fatigue, lifestyle

Sexual Aversion Disorder—phobia or panic level
 May be related to a hx of erectile problems in men;
also to rape or sexual abuse
Sexual arousal disorders


Previously called impotence and frigidity
Male erectile disorder—
 Situational vs. generalized; primary vs. secondary
 Performance anxiety—big cause; also depression, s-e, etc.
 10% of men experienced erectile problem in last 12 mos—varies
with age
 50-80% are due to organic factors—vascular problems,
diabetes, spinal cord injury
 Exercise, wt loss, lower cholesterol all improve sexual
functioning

Female sexual arousal disorder—both subjective arousal
and lubrication




19% of women have problems with lubrication
Often goes with other sexual disorders like HSDD
Usually situational
More commonly has psych causes—anger and resentment
toward partner, sexual trauma, anxiety, guilt, ineffective
stimulation
 But physical causes also possible—vascular damage,
decreased estrogen
Orgasmic disorders

Male orgasmic disorder—cannot have orgasm even
when highly aroused and had a great deal of
stimulation
 8% in last year –not necessarily dx
 most often is limited to intercourse
 bio causes-MS or neuro condition, side effect of meds,
ETOH abuse
 also psy causes—hostility, anxiety, guilt

Female orgasmic disorder
 24% of women in last 12 mos
 accts for 25-35% of cases of female sex tx
 may be related to education, also to spectatoring

Premature ejaculation—hard to define—but too rapid to
permit selves or partner to enjoy sex fully. Def varies-<30 sec, <1min, or no voluntary control
Sexual pain disorders

Dyspareunia—painful coitus
 14% women, 3% men
 In women, most common cause—lack of lubrication
 Can also be caused by allergies to spermicides etc.,
vaginal infections, STDs, PID
 Psych causes—guilt, anx, sex trauma
 In men—genital infections, smegma

Vaginismus—involuntary contraction of the
pelvic muscles that surround outer 1/3 of vaginal
barrel.
 Intercourse is painful or impossible.
 12-17% of women seeking sex tx.

Not conscious. Not bio based.
Biological causes
Always have a physical first!
Fatigue—erectile dysfunction, orgasmic
disorders
 Poor general health is related to most of these
problems.
 Alcohol—interplay of expectancy and actual
effects


 Low levelsexpectancy
 High levelsdepressant
Cocaine—can decrease sexual desire, cause
erectile or orgasmic dis.
 Vascular problems

Psychological causes

Cultural influences
 cultures that have more negative attitudes toward sex
have more dysfunctions
 anxiety and shame
 women here are taught to be repressive, self-controlled—
sexually active but anorgasmic
 negative attitudes toward masturbation, sex guilt, greater
discomfort talking about sex

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
Ineffective sexual techniques
Irrational beliefs
Performance anxiety
Sexual trauma
Sexual orientation
Problems in the relationship
Emotional factors
Sex therapy

5 goals
 1) Change self-defeating beliefs and




attitudes
2) Teach sexual skills
3) Enhance sexual knowledge
4) Improve sexual communication
5) Reduce performance anxiety
 Therapy usually involves both partners
 Bio tx also available—viagra
Masters and Johnson
Focus on problem behavior—not cause and how it
could be changed
 Their original program was 2 week residential
 Developed sensate focusing
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One partner caresses the other
The other communicates what is pleasurable
No performance demands
Intercourse is initially forbidden
6 elements (Masters & Johnson, 1970)

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Both partners
Male and female sex therapist
Dysfunction is conceptualized as learned—therefore, education
Key causes—performance anxiety, fear of failure, excessive
need to please partner
 Communication is critical
 Treatment is progressive—tasks and behavioral prescription
Other approaches

Kaplan’s approach
 Not rigid two weeks, but short term
 Participation of both is crucial, but not equally
 Key—overcoming resistance

PLISSIT Model (Annon, 1976)
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Permission-encourage discussion, “normalizes”
Limited information—education, dispelling myths
Specific suggestions
Intensive therapy
LoPiccolo’s Approach
 Systems therapy
 Integrated (physical and psychological) planning
 Sexual behavior patterns
Other approaches

Cognitive-behavioral tx—teach script flexibility—novelty
is good
 Need to make sure that relationship out of bed is a good
one
 Restructure negative thoughts—all or none thinking
 Education is important

Surrogate Partner Therapy
 Rare
 60+ hours of training

Specific techniques
 Start-stop techniques
 Guided masturbation—treats orgasmic disorder in women
 Kegel exercises—helpful for women with poor muscle
tone after childbirth, increases sexual pleasure by
increasing sensitivity of vaginal area
Evaluation
 Masters and Johnson (1970) reported overall success rate
of 80%
○ After 5 years, 7% relapsed (but only followed up with 29% of
sample)
 Success varies by dx
○ Vaginismus 80%
○ Premature ejaculation 90%
○ HSDD—most difficult to treat successfully
○ After program of directed masturbation, 95% of women could
have orgasm, 85% with partner, only 40% during coitus
 Tx works best when couples are motivated and get along
well in other areas
 Common factors—Miller, 2001
○ No difference by technique
○ Extratherapeutic (40%)—any and all aspects of client and
environment that facilitate changes
○ Relationship (30%)—rapport with therapist
○ Placebo/hope/expectancy (15%)
○ Structure/model/technique (15%)
Illness, disability, drugs, and
sexuality







About 12% of US is disabled, meaning they
have functional deficits in performing ADLs
Myth of asexuality
Illness and self-concept/body image
Believe they are less sexually desirable
Schover, 2000—men are vulnerable to low SE
if unable to earn income or perform sexually,
may withdraw if they feel ashamed about
dependency
But 78% report high of moderately high SE
But on average lower SE than non-disabled
Impaired sensory-motor function

Stroke
 Associated with decrease in sexual desire, erectile functioning,
orgasmic ability, vaginal lubrication, and coital frequency
 Why decrease in sex?
○ Fear of impotence
○ Inability to discuss sexuality
○ Unwillingness to participate in sexuality

Spinal cord injury
 82% are men. Most between 16 and 30
 MVA (36%), violence (29%), falls (21%)
 Some sexual arousal in most spinal cord patients
○ Moin et al 2009
 Women with physical disability had the same sexual needs and desires as women
without disability
 Body image, sexual self-esteem, sexual satisfaction and life satisfaction were
significantly lower
 Differences were stronger among young adult women than among more mature women
○ Singh & Sharma, 2005 Concerns about dysfunction, bladder/bowel dysfunction, bed sores, pain, spasticity,
satisfaction of partner
 Less likely to marry
Multiple sclerosis and cerebral
palsy

MS—progressive CNS disease, onset between
20 and 40
 2-3x more common in women, northern latitude
 Sexual dysfunction is common—decreased genital
sensation, genital pain, vaginal dryness
 Tends to increase in severity over time

CP—brain damage before, at birth, or in infancy
 Need counseling and assistance to achieve
satisfaction
 Wiegerink et al 2008
○ Psychological maladjustment, insufficient self-efficacy and
low sexual self-esteem may impair the development of
social and sexual relationships.
○ Overprotection in raising children with cerebral palsy and
the negative attitudes of other people may have a
negative influence on the self-efficacy of people with
cerebral palsy
Diabetes
6% of population, about 1 million Type 1,
15 million Type 2
 1/3 unaware of diagnosis
 Women

 Lack of libido, diminished clitoral sensation,
orgasmic dysfunction, vaginal dryness

Men
 Progressive softening of penis
 Can be permanent damage to ANS
Alzheimer’s and other dementias
 Alzheimer’s –about 2/3 of all dementia
 Often exhibit inappropriate sexual and
social behavior
 Davies et al, 2010
○ Dementia caregivers report difficulties with
communication, cohesion, and perceptions of
increased burden
○ Reduced sexual expression due to physical
limitations; substitute activities including handholding, massaging, and hugging
Intellectual disability

Sexual consent capacity





Can say no
Know that intercourse can lead to pregnancy
When given options, can make informed choice
Know sex can lead to a disease
Can distinguish between appropriate and inappropriate times to have
intimate relationships
 Differentiate between men and women
 Can recognize threat
 Will stop if another person says no



History of eugenics—23 states between 1907 and 1927
Families are less open to intimate relationships than are
caregivers of ID people (Evans et al, 2009)
Healy et al, 2009
 Young people had only rudimentary knowledge of sexuality issues, for
example pregnancy and sexual anatomy,
 Aspired to relationships and marriage similar to non-ID

Family and staff attitudes --very influential
Mental illness and sexuality
40% of individuals in US will have mental illness in
lifetime
 Some mental illnesses and treatments are associated
with decreased sexual functioning
 Major depression—related to increased erectile
dysfunction, decreased sexual desires

 Antidepressants—decrease arousal and desire
 30-60% of those taking SSRIs report dysfunction

Schizophrenia
 May have symptoms related to sex
 Antipsychotic medications can eliminated these sx
○ But—decrease sexual desire, increase erectile dysfunction and
ejaculatory problems


Serious mental illnesses increase risk of victimization
Impaired judgment
Medical treatment and sexuality

Some surgery can improve sexual feelings
 Endometriosis
 Back surgery

Others are negative
 Pelvic surgery can damage pelvic autonomic nerves

Hysterectomy

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
About 1/3 are medically unnecessary
Often performed for benign conditions
About ½--women lose both ovaries
No longer experience uterine contractions—orgasm may change
But in a study of 1000 women, most reported good orgasms,
increase sex frequency, and decreased sexual dysfunctions
Medication
 Many interfere with sexual functioning
 Antidepressants, antihypertensives, drugs that treat heartburn

Chemotherapy—nausea and fatigue
Alcohol, other drugs, and
sexuality

Substance abuse—1 of…
 Failure to fulfill role obligations at work, school,
or home
 Use in situations in which it is hazardous
 Substance-related legal problems
 Continued use despite negative effect on
relationships

Substance dependence




Tolerance
Withdrawal or avoidance of withdrawal
Failed efforts to quit
Giving up activities due to use
Alcohol and substance use

62% of US adults are current drinkers
 5.7% of men are heavy drinkers (>14 per week)
 3.8% of women (>7 per week)
¼ of teens and young adults (15-24) report
unprotected sex because of drinking or drugs
 Expectancy effects


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
Enhanced sex
Decreased nervousness
Increased riskiness
Greater expectancy effects in heavy drinkers
Long term use
 Alcoholism in men leads to decrease in testosterone,
less facial hair, breast enlargement, lower libido,
erectile dysfunction,
 Women—early menopause
STDs
Centers for Disease Control, 2007 report
 19 million new STDs in US each year, about 350 million worldwide



Nearly half among those 15-24
About half of all sexually active young people will contract an STD by 25
Costs US about $15.9 billion/year
Two most common infectious (bacterial) diseases in the US:
gonorrhea and Chlamydia (about 1.5 million total—1.2 Chlamydia,
300,000 gonorrhea)
 Undiagnosed/untreated STDs cause about 24,000 cases of
infertility each year



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STDs are associated with


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
Accounts for 15-30% of all infertility
Low SES
Drug use (increases risky sexual behavior)
Sexual abuse—about 2x as likely
Lesbians are at decreased risk
Bacterial vs viral infections
Consequences of STDs

Health consequences
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Economic consequences
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
PID
Transmission to fetus, newborn or infant
Infertility
National
Treatment—HIV meds may be $1000/month
Psychological consequences
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Shock
Withdrawal from social interactions
Anger
Fear
Shame
Depression
In one study of 736 people with AIDS, >40% depressed
Young et al, 2007
○

Potential moral stigma leads people to underplay their susceptibility to sexually
transmitted diseases
Dampens their interest in getting tested
Gonorrhea
Used to be the most widespread STD in the US
 African Americans comprise 12% of population but 70% of
gonorrhea—one of the largest racial disparities among all diseases
 Symptoms


Men
○

Women
○
○
○

Yellowish, thick, penile discharge, burning urination
Increased vaginal discharge, burning urination, irregular bleeding
Often no early symptoms
Can cause PID
Transmitted almost always through oral, anal, or vaginal sex or
during delivery.

Needs warm, moist place to live—dies on toilet seats in a minute
May cause blindness in babies—why babies need silver nitrate
If untreated in men, may cause sterility
Highly contagious—women have 50-90% chance of getting it in just
one exposure, men 20-25%
 Treated with antibiotics



Syphilis
13,500 cases of syphilis in 2008
 Increasing since 2001





Due largely to male to male sexual contact
Record low of 5,979 in 2000
Transmission through sex or through touching a chancre
Pregnant women can give to babies through placenta

Causes miscarriage, stillbirth or congenital syphilis—impaired vision and
hearing, deformed teeth and bones
 Fetus not harmed if mother is treated before 4th month

4 stages

Primary
○
○
Painless chancre—hard, round, ulcerlike lesion
Secondary

○
Latent


○
Sx go away—dormant for 1 to 40 years
Still multiplying and getting into CNS, circulatory system, bones
Tertiary or late stage

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
○
Skin rash--painless red bumps that darken, burst, ooze, h/a, fever aches, flu-like
Attacks CNS or cardiovascular system
Can be fatal
Neurosyphilis—brain damage, paralysis, insanity
Can be treated in primary or secondary stages, not after
Chlamydia



92 million new cases worldwide each year
Transmitted vaginally or orally. May also causes eye
infection if person touches eye after genitals of an infected
person
Also transmitted during birth as child passes through cervix
 Each year, about 100,000 babies are infected with bacterium
○ 75,000 will develop eye infections, 30,000 pneumonia
 Can cause blindness—used to account for 15% of all blindness,
now less than 4%

Symptoms
 Similar to, but more mild than, gonorrhea
 Men—nongoncoccal urethritis (NGU) (means not from
gonorrhea)
○ Thin, whitish discharge, soreness in scrotum, pain in urination
 Women—cervicitis, urethritis, endometritis, PID
○ Also—burning during urination, vaginal discharge, pelvic pain, can create
infertility, increased chance of ectopic pregnancy


25-25%men, 70-85% women are asymptomatic
Treated with antibiotics
Vaginal infections

Yeast infections

Candidiasis
○
○
○

Sx in women
○



Itching, burning, soreness, inflammation, white discharge
Can be passed between partners during oral sex (thrush in mouth)
Also can be passed to men
○

BCP, antibiotics, diabetes, menstruation, pregnancy can increase risk
Diet high in dairy, sugar, artificial sweeteners
Eating pint of yogurt/day decreases recurrences
Sx are itching and burning during urination, reddening of penis—genital thrush
75% of women will have at least one
Trichomoniasis

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Most common curable STD among young, sexually active women
7.4 million new cases per year
Parasite
Creates foamy whitish to yellow-green discharge, itch/burn
Pain during sex or urination, 5-12% report abdominal pain
Can be passed from men to women, towels, sheets, toilet seats
Most men are symptom free
Treat both partners
Increases susceptibility to HIV in women exposed to HIV
HIV

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In 1981, when AIDS was 1st found in medical journals, fewer
than 100 Americans had died from it
By 2000, nearly 725,000 had AIDs and nearly 500,000 died
from it
850-950,000 currently living with it
180-280,000 don’t know they’re infected
Leading killer of Americans 25-44
What are risks?

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Unprotected sex
Sharing needles
Blood transfusions (screened here, less elsewhere)
Mother’s milk
Mother to unborn baby
Professional
Not saliva, tears, urine
HIV

Factors that affect risk


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
First symptoms of HIV infection


# of sexual contacts
Type of sexual activity (anal intercourse increases risk)
Amount of virus in fluid
STDs that inflame genital region or create ulcers
Circumcision decreases risk
Genetics
Male to female transmission is 12x greater than female to male
Untreated, 1/3 of babies of infected mothers get HIV. With AZT and c-section,
this risk is 3-5%
Mild flu-like
To diagnose AIDS


T-cell count less than 200
Opportunistic infection
Confidential vs anonymous testing
Window is 30-90 days
 22.4 million people in Africa—2/3 of world’s total of HIV/AIDS





2008—1.9 million became infected with HIV
2008—1.4 million died from AIDS
Life expectancy in sub-Saharan Africa is now 47 (used to be 62)
Genital herpes

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
16% of people 14-49 in US
Two types: HSV I and HSV II
Estimated that 100 million people have oral herpes
Transmitted through oral, vaginal, anal sex. Can survive for
hours on objects such as toilet seats. Oral herpes can be
transmitted by sharing a cup, kissing, sharing towels
No cure. No vaccine
Blisters may be given a topical to relieve pain, speed
healing. Medications to reduce outbreaks
Recurs during stressful times. Transmission more likely
during flare-ups.
Can be transmitted elsewhere on body—ocular herpes
Can be transmitted to baby during birth
Coping—herpes syndrome





Feelings of anger, depression, isolation
Feeling tainted, ugly, dangerous, damaged
75% avoid sex for a long time
May seek infected partners so they don’t have to explain
People perceive herpes as having serious consequences
Human Papilloma Virus

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Genital warts
More than 40 types
Approximately 20 million Americans are currently
infected with HPV. Another 6 million people become
newly infected each year.
Each year, about 12,000 women get cervical cancer in
the U.S.
May be visible, but in 7/10 not—cervix, urethra
Appear 2-3 months after sex with infected person
Cervical abnormalities in 40-50% of women with
HPVincreases risk of cervical cancer
Actually similar to plantar warts—hard and yellow gray
when on dry skin, pink, soft cauliflower-like in moist
areas
Can also form other places—lips, eyelids, nipples,
around anus
Transmitted through skin to skin contact during sex
Treatment and vaccines
Treat –freeze off with liquid nitrogen or
paint with alcohol-based solution, but virus
remains
 Vaccines can protect males and females
against some of the most common types of
HPV.

 These vaccines are given in three shots. It is
important to get all three doses to get the best
protection.
 The vaccines are most effective when given
before a person's first sexual contact, when he
or she could be exposed to HPV
Pubic lice
Related to head lice
 Large enough to be seen with eye—1.1
to 1.8 mm
 Spread sexually, by infected towel

 Not likely to be spread by toilet seat
 Can only survive 24 hrs without human host,
but can lay eggs that last 7 days


Itchy
By the way—animals do not get or
spread this
Prevention of STDs










Know the risks
Abstain
Stay sober
Inspect yourself and your partner
Use latex condoms
Wash genitals before and after sex
Avoid high-risk sexual behavior
Get regular medical check ups
Know your partner—encourage testing
Avoid other high risk behaviors—sharing
needles, towels, cuticle scissors, razors
Normal vs. deviant sexual
behavior
Statistical infrequency
 Deviation from social norm (moral
correctness)
 Naturalness
 Adaptiveness/comfort

Paraphilias






Recurrent, intense sexually arousing fantasies
that generally involve nonhuman objects,
suffering or humiliating oneself or one’s
partner, or nonconsenting people
Usually feel urges are insistent, compulsive
quality.
Nearly all male.
Vary in severity
Usually occur in clusters—over half show
more than one
To dx, must be present for 6 months. There
are 8 paraphilias, 5 of which we can dx if
people act on them, regardless of whether or
not the person experiences distress
Fetishes

Sexual fixation on some object other
than another human and attachment of
erotic importance to that object
 Media—type of material
 Form—particular shape
 Related—partialism—excessively aroused
by a particular body part

Not typically harmful
 Generally private, consent of partner

Typically occurs before puberty
Transvestic fetishism






Up to 6% of men by some estimates
Cross dressing does not equal transvestism—some
men dress in drag for other reasons
For the transvestite—sexually arousing
Not typically harmful—typically in private or with
consent of partner
Generally have a strong male identity (68% hetero)
Origin unknown
 May be related to family somehow

Most keep transvestism secret, even from partners or
wives
 When wives find out, most are confused or shocked
○ Most try to be understanding at first
○ Later become more negative

Reasons as adults—sexually arousing, relaxing, role
playing, adornment
Exhibitionism

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




Sexual arousal from exposing genitals to others in culturally
inappropriate situations
Cross-culturally, fewer than 20% are reported to police
1/3 of college women have been victims of this
30% of all arrests for sexual offenses are for flashing
About 10% of rapists and child molesters (in one sample) began as
flashers
Urge to exhibit begins in early adolescence., exhibitionism itself
usually begins before age 18. Frequency declines after 40
What they are like:

Typically young, unhappily married, timid, unassertive, lacking in social skills,
lacking in sexual skills, doubts about own masculinity, suffer from feelings of
inadequacy, many report overprotective mothers and poor rel. with fathers
Preferred victims are girls or young women
Indirect means of expressing hostility toward women, but they
aren’t in touch with this
 About 50% report erections during, usually masturbate later


Telephone scatalogia





Few are women—women who do this are
typically motivated by rage/revenge
Males—motivated by desire for sexual
excitement
Most aren’t dangerous, don’t make
repeated calls to the same person
Many patterns—obscenities, breathe
heavily, sexual overtures, sex surveys, etc.
Like exhibitionist-socially inadequate
heterosexual male who can’t form intimate
relationships
Voyeurism







Become sexually aroused from secretly
viewing nudes
Usually begins by age 15. Almost exclusively
found in males
Unsuspecting is key—not pornos or strippers
Most are nonviolent, but may be violent if
provoked
More dangerous—1) those who break in 2)
those who draw attention to themselves
Risk is an element of the arousal
Tend to be less sexually experienced, not
likely to be married, harbor feelings of
inadequacy, lack social skills, less likely to
have sisters or female friends
Sadism and masochism
Masochism is the only paraphilia found with any
frequency in women—about 5% of masochists are
women
 Sadomasochism is highly ritualized—not all pain is
gratifying
 In a mild form—not uncommon

 Kinsey found 26% men and women found being bitten
erotic as part of sex act
 22% men, 12% men reported arousal to S&M stories
Pain may be symbolic
Serious injury is usually avoided
Survey from S&M magazine—3/4 male, most married,
men interested since childhood, women introduced to it
 Causes—may have bio links to pleasure—pain causes
release of endorphins, but this doesn’t explain symbolic
pain or sadism



 Learning theorists—being spanked for masturbation
 Sociologists—losing control, letting go
Frotteurism
Rubbing or touching a nonconsenting person
Buses, subways, elevators
May imagine a consensual relationship—in
reality, are very afraid of rejection
 Japan



 Street groping is called chikan and the man who
commits such acts is also called chikan
 Crowded trains are a favorite location for groping,
and a 2001 survey conducted in two Tokyo highschools revealed that more than 70% of students
had been groped while travelling on them
 Some railway companies designate women-only
passenger cars during rush hours

Chikan is often featured in Japanese
pornography
Other paraphilias
 Zoophilia
Necrophilia
 Klismaphilia—enemas
 Coprophilia—feces
 Urophilia--urine

Origin of paraphilias

Psychoanalytic theory
 Unconscious conflicts
○ Domineering mother
○ Unresolved Oedipal conflict

Feminist perspective
 Pedophilia, sadism—aggression
 Traditional gender roles emphasize male dominance,
sexual aggression, control, hostility

Learning theory
 Classical and operant

Biological theory
 Paraphilias correlate with other mood disorders like
depression, anxiety, and bipolar

Paraphilias as vandalized lovemap
 John Money
 Mental template that develops early in life
Prevention
3
components of sexual development
 Gender identity
 Sexual responsiveness
 Formation of relationships with others
 Different components in each diagnosis
Treatment

Problems—
 1) Don’t want/seek tx
 2) No motivation to change even if in tx (thus cog tx doesn’t
work)
 3) Should therapist impose own goals?
 4) Perceived responsibility—client must know he can change

Behavior tx
 Systematic desensitization—pair relaxation with arousing
images
 Aversion tx—shock, nausea inducing drugs
 Social skills training
 Orgasmic reconditioning—begin with old images, then switch to
appropriate ones

Drugs
 Prozac—some effectiveness for exhibitionism, voyeurism,
fetishism (OCD-type beh)
 Anti-androgen drugs—depo provera—decreases sexual desire
in those at risk for sexual offenses. Decreases desire—not
urges or behavior in a particular direction. High refusal and drop
out rates for this treatment.
Exploitative dating relationships
Types of abuse
 Emotional/mental/verbal
 Environmental
 Social
 Financial
 Religious
 Sexual
 Physical

Prevalence of abuse



Prevalence estimates vary greatly, but it appears that dating
violence begins around age 15
Domestic violence rates mirror the country’s homicide rates.
Marquart and colleagues (2007) examined dating violence in
20,274 rural adolescents
 16 % reported being a victim of dating violence.

Raiford, Wingood, and DiClemente (2007) examined dating
violence in 14-17 year old African American girls over a oneyear period.
 When the study began, 28 % reported already having a history
of dating violence. Of these, 47 % reported both verbal and
physical abuse, 35 % reported verbal abuse only, and 18 %
reported physical abuse only. An additional 12 % were abused
over the course of the one-year follow up period.

Across studies, a prevalence rate of between 20 and 45 %
seems to be accurate (Lewis & Fremouw, 2001).
Attitudes toward abuse
Boys and girls are more accepting of
girls’ use of violence than boys’, though
it should be noted that girls’ violence is
often less severe.
 Further, boys are more accepting of
violence across the board than girls
(Price et al., 1999).

 More accepting attitudes toward violence
are related to likelihood to use violence
Correlates of abuse














Use of alcohol and drugs (twice as likely)
Lower school performance
Exposure to family violence
Witnessing or having a knowledge of community violence
Having a greater number of sexual partners
History of depression and suicidal thoughts
Traditional gender role attitudes and attitudes toward dating
violence
Peer influence
Drinking prior to sex
2 times more likely to report less understanding of healthy
relationships
1.9 times more likely to have viewed x-rated movies
Exposure to such movies leads to attitudes condoning violence.
Rates are 1.5 times higher among African American girls than white
girls, according to the national Youth Risk Behavior Survey (Howard
et al., 2007)
Dating violence is correlated with feelings of sadness and
hopelessness, but it is unclear which comes first (Howard et al.,
2007)
Among perpetrators
PTSD is associated with dating violence
among those who have a history of
maltreatment (Jonson-Reid et al., 2007;
Wekerle et al., 2001)
 Boys and girls are equally likely to be
perpetrators (Jonson-Reid & Bivens, 1999)
 Anger control skills, religiosity, parental
monitoring and support, and perceived
social status are all protective factors
against adolescent aggression in general
(Fergus & Zimmerman, 2005)

Rape
How common?
 Definitions vary and way info is gathered
varies, leaving wide estimates in how
common this is.
 Somewhere between 14% and 25% of
women in US are raped in their lifetimes.
Reported rapes are 20x greater than
Japan, 13x greater than GB

Types of rape






Stranger—4%
Spouse—9%
Acquaintance—19%
Know well—22%
In love with—46%
Some studies have found rates of 80% by
acquaintance or known person—these #s are
hard to call because they may not perceive
themselves as victims. Perhaps 5-16% of
acquaintance rapes are reported.
 In one study of college women who had been
sexually assaulted, only 27% saw selves as rape
victims
Why underreport?






1)Might not fit her idea of what a real rape
is, even though she still feels the trauma
2) Might blame herself or be aware that
others will
3) Might not recall incident well because of
alcohol or drug use
4) Mistrust of police or legal system
5) Fear reprisals from rapist, his friends or
his family
6) Fear publicity
Is rape a crime of violence and
power or sex?

Both.
 1970s—big thing about power
 But sex seems to be a part of it
○ Victims tend to be in teens/early 20s
○ Rapists cite sexual motives
○ Rapists share similarities with some of the
paraphilias
Why do men rape?
 Rape
myths
 Men in general are more accepting these
and cling to these more tenaciously even
after education. Men who rape are more
accepting of these.
 Gender
roles that encourage men to
be dominant, women helpless
 Traditional masculine menmore
likely to rape
Who rapes?














60 are under 25
Hypersexual peer group
Sexually active, but actually know little about sex
Low SES
Prior criminal record
Accepting of rape myths
Date rapists—tend to be more middle to upper middle
class
Poor cognitive appraisal of women (believe women lie)
Poor social and communication skills
Impulsive
Sexually aroused by depictions of rape
May have hx of sexual abuse
Use strength to get what they want
No evidence of media influence
Marital rape
Marital rape exemption
 Dates back to 17th century legal concept
 Massachusetts put this into law in 1857 and all other states
followed.








Muslim delegates to UN had marital rape excluded from a human
rights declaration on violence against women in 1995
Many countries have made this illegal, but not all
Tajikistan--47% of married women reported having been forced to
have sex by their husbands
In Turkey 35.6% of women have experienced marital rape
sometimes and 16.3% often
Countries that have not made it illegal include: Afghanistan,
Bahamas, Ethiopia, Honduras, Kenya, Mongolia, Nigeria, Pakistan,
Sri Lanka (except in cases of separation), Sudan, Yemen, Zambia
Why marital rape?




All states have no repealed this
Domination, degradation
Often as part of other violence in the home
Not due to sexual deprivation
Rarely reported
Male rape
Maybe 1/10 rape survivors is male
Compared to female, more damage to body
Often perpetrated by men, though a few by
women
 Primary purpose: to degrade and humiliate
 1.5% of women report forcing a man to have sex
at least once (compared to 2.8% of men)
 Donaldson’s work on rape in prison



 1-3% (conservatively) raped each year in prison
 Surveyed prisoners and staff
○ 38% inmates, 39% staff
○ Those who didn’t respond thought they were working with
DOC
○ 20% inmates had been sexually assaulted
 12% anal or oral sex
 8% verbally pressured into sex, grabbing or fondling
○ Staff consistently reported lower rates of rape
Psychotherapy for offenders
Difficult to treat successfully
 Meta-analyses show modest effects
 Cognitive-behavioral techniques are
most effective
 Nonpedophile child molesters and
exhibitionists respond better than
pedophiles and rapists

Rape and its aftermath






Many people believe women are at least partly
responsiblesurvivors often feel guilt/shame
Repetitive, planned activity rather than a single event
Immediately after—trouble sleeping, crying, fear of being
alone, fear of sex, eating problems, headaches, irritability,
withdrawn
Distress peaks about 3 wks after, stays high for a month,
then begins to decline
Physical trauma combines with psychological factors (rape
trauma syndrome)
One survey of women
 2/3 told someone
 1/10 told police
 1/6 contacted mental health professional


Negative impact on victim’s intimate relationships
STDs
Post-Traumatic Stress Disorder
and Acute Stress Disorder
 Difference between the two is timing—Acute Stress occurs right
after the event, lasts from 2 days to 4 weeks. After 4 wks after
the event, it is PTSD. Onset can also be delayed for PTSD
beyond 6 months.
 Symptoms:
○ Frequent reexperiencing of the event through intrusive thoughts,
flashbacks, nightmares, and dreams
○ Persistent avoidance of stimuli associated with trauma and a general
numbing or deadening of emotions
○ Increased physiological arousal with an exaggerated startle response
 Causal factors/risk factors:
○
○
○
○
○
○
Perception of trauma
Social support (why rates were somewhat higher for Vietnam Vets)
Those who develop it tend to have preexisting more somatic concerns
More social maladjustments and irresponsibility
Be more passive and inner directed
Be more sensitive to criticism and suspicious of others
 Approaches to treatment:
○
○
○
○
Short-term crisis therapy—face to face discussion
Direct exposure therapy—in vivo or imagined
Telephone hotlines
Psychotropic medications
Recovery from rape






Survivor can think about assault when s/he
wants to without intrusive flashbacks,
memories, nightmares
Can remember it with appropriate emotions
instead of numbness or false detachment
Can identify and endure emotion without being
overwhelmed
Level of depression, anxiety, sexual
dysfunction drop to at least a tolerable level
End social and emotional isolation by reestablishing relationships with others
Self-esteem is stronger than self-blame
Childhood sexual abuse

How common is abuse?
 NHSLS—17% men, 12% women
 According to DHHS in 2008
○ Of the 772,000 victims of child maltreatment in Federal
fiscal year 2008,
○ 71.1 percent experienced neglect
○ 16.1 percent were physically abused
○ 9.1 percent were sexually abused
○ 7.3 percent were psychologically maltreated
○ 2.2 percent were medically neglected
○ 4.2 percent of victims experienced other types of
maltreatment such as abandonment, threats of harm to
the child, and congenital drug addiction

More common these days—both better
recognition and a genuine increase
Types of abuse
 Genital fondling most common –38%
 Exhibitionism 20%
 Intercourse 4%
Who is abused?

Girls>boys. Between 78 and 89% of victims
are female
 Boys are more likely to be abused in public and by
strangers
 Boys are also more likely to be threatened or injured




Age is unclear.
Race is inconclusive
Some studies find more among kids from low
SES. It appears that it is less related to low
income than other types of abuse
Related to other family problems like
parental alcoholism, parental rejection, and
parental marital conflict
Who abuses kids?

Overwhelmingly male
 Over 90% are men overall
○ 94-100% who abuse girls are men
○ 84% who abuse boys are men
○ Little research on female abusers—may be more common than
believed because women have a freer range of contact



About a third of those who sexually abuse are juveniles
Young adults under 30 are also overrepresented
Most abusers are known to the child
 About half are acquaintances
 Family member rates vary from 14-47% (about 1/3 sounds right)

Between 7 and 25% are strangers
Consequences of child sexual
abuse




PTSD, low self-esteem, depression, anxiety, sexual
precocity, sexual withdrawal
About 1/3 show no signs
About 1/3 will go on to offend themselves
Effects are more negative






Ongoing
Penetration
Threat or force
Step or bio father
Effects are less negative if there is parental support
Much of the past research has not separated single vs.
multiple events
 As a result, some research suggests fewer negative effects on
boys
○ This is misleading
○ Study of 1500 12-19 yo youth
 Abused males are 11x more likely to have suicide attempts or thoughts
 Increased addiction risk
 Increased risk for criminal behavior
Incest

Brother-sister is most common and not always harmful
 21% college men, 39% college women in one study
 Brother usually initiates
 Some may not know it is taboo--exploration

Father-daughter is second most common
 1-4% of women report this
○ More common with stepfathers
 Younger daughters—more socially inept, dependent
fathers
 Older daughters—more authoritarian, angry fathers
 Fathers who are actively involved in child care are less
likely to abuse

General family disruption—conflict, abuse, alcoholism
 Marriage may be uneven in power
○ Husband is dominant, but wife is sexually rejecting

1/3 of male abusers, ½ of mothers (not abusers) had
been molested themselves
Pedophilia





Recurrent intense sexually arousing
fantasies, urges, and behaviors involving
sexual activity with a prepubertal child
Nearly all pedophiles are male; 2/3 of
victims are girls
Pedophiles are more likely to believe that
children benefit from sexual contact
Begins in adolescence and persists over a
person’s life
Tend to be shy, introverted, yet still desire
to have mastery or control over someone
Child pornography

Reijnen et al, 2009
 Compared to other sexual offenders internet
child pornography offenders were
○
○
○
○

Significantly younger on average
Were single
Lived alone in most cases
Have no children of their own
Endrass et al, 2009
 Study of offenders in Switzerland
 Those who download child porn are not at a
hugely increased risk of hands-on child
molestation
Views of those who sexually
abuse


Mears et al, 2008
94% of Americans agree that sex crimes should be a state
and federal policy priority
 54% strongly agree that such crimes should be a priority







Americans also overwhelmingly support registries,
restrictions on where sex offenders can live, and
incarceration
46% think that individuals convicted of indecent exposure to
an adult should be jailed
97% of the public support prison or jail terms for sexual
assault or rape of a child
80% support such terms for indecent exposure to a child
89% support terms of incarceration for individuals convicted
of distributing child pornography
68% support imprisonment for individuals convicted of
accessing child pornography
Males, whites, the less highly educated, and the less wealthy
are all more supportive of incarceration and tougher
sanctions generally
Sexual harassment


Sexual harassment is a form of sex
discrimination that violates Title VII of the Civil
Rights Act of 1964
Unwelcome sexual advances, requests for
sexual favors, and other verbal or physical
conduct of a sexual nature constitutes sexual
harassment when submission to or rejection of
this conduct explicitly or implicitly affects an
individual's employment, unreasonably
interferes with an individual's work
performance or creates an intimidating, hostile
or offensive work environment.
Effects of sexual harassment








Decreased work or school performance; increased
absenteeism
Loss of job or career, loss of income
Having one's personal life offered up for public scrutiny—
the victim becomes the "accused," and his or her dress,
lifestyle, and private life will often come under attack.
Loss of trust in environments similar to where the
harassment occurred
Loss of trust in the types of people that occupy similar
positions as the harasser or his or her colleagues
Extreme stress upon relationships with significant others,
sometimes resulting in divorce; extreme stress on peer
relationships, or relationships with colleagues
Weakening of support network, or being ostracized from
professional or academic circles
Loss of references/recommendations
Prostitution




17% men, 2% women in NHSLS reported ever using
Most are occasional users—1/2 are regulars
About 40% of users are married
Average user






35 yo
1 or 2 years of college
White (slightly over ½ of users)
Avg of 4 sex partners in previous month, of whom 2.5 were paid
In other words: middle-aged, middle class, married
Motives






Sex without negotiation
Sex without commitment
Sex for eroticism and variety
Prostitution as sociability
Sex away from home (greatest contemporary use)
Problematical sex
Prostitution as a career

Ecology of prostitution
 Complex set of relationships among a number of
professionals
○ E.g., police and prostitutes where prostitutes are snitches
○ Other relationships: pimps, madams, politicians, social
welfare workers, night club owners
○ Hard to regulate—when it is allowed in one area, it
migrates
 It is work
○ Hours are generally fixed by someone else
○ Tasks are set by someone else
○ S/M workers increasing—deemed safer than vaginal, anal,
or oral sex
○ Most prostitutes were pushed into the job by need for
money
 Career patterns
○ Hard for women to visualize how to change
Types of prostitutes

Street walker




Most prostitutes
Greatest risk of abuse by pimps/customers
80% (at least) are survivors of rape or sexual abuse
Most report having enjoyable sexual relationships in
private lives
 Many have pimps who keep 90-95% of earnings
 Most don’t stay in the business long—straighten up, age
out, or die young

Brothels
 Rare except Nevada (regulated by counties—not allowed
in whole state)



Massage parlors
Escort services
Call girls
Characteristics of prostitutes
Poverty—main reason to be a prostitute throughout
history
 Emotional problems are big contributor also
 Farley et al 1998

 Across countries, 73% reported physical assault in prostitution
 62% reported having been raped since entering prostitution
 67% met criteria for a diagnosis of PTSD
 92% stated that they wanted to leave prostitution

Teen prostitutes in US






High levels of psychological disturbance
Increased rates of special education
Many are runaways
Lots of family dysfunction
95% are victims of sexual abuse
One study of runaways in Toronto
○ 67% boys and 82% girls were offered money for sex
○ 20% said yes

Majority from single parent homes
Male sex workers




Gigolo for women, hustler for men
Hustlers are far more common
Like women, street vs escort services
Smith & Seal, 2008
 Escort service workers-lower rates of HIV risk behavior
with clients than street-based MSWs

Timpson et al 2007





Study of 179 male sex workers
172 reported crack use
Average age of 31
½ considered themselves homeless
In the past 30 days they reported an average of 56 male
partners and 5 female partners.
 Of the 179 men, 152 had been tested for HIV and knew
their status. Twenty-six percent of those tested had tested
positive
Pornography
Pornography—sexually arousing art,
literature, film
 Obscenity—offensive to standards of
decency
 Erotica—arousing but not degrading or
demeaning

Pornography







Increasingly online—most viewed topic on the
internet is sex
Over 100,000 sites
Most popular sites report 50 million hits
The majority of Internet pornography users are
recreational basis with 43% spending less than one
hour per week
6-10% using more compulsively, spending six hours
or more per week
Affordable, accessible, anonymous
Cooper et al 2004--about 9 – 15% experience
various indices of distress – about the same
percentage of people who are using 11 or more
hours per week
Gender and porn
About 85% of users are male
Women are more likely to use porn chat rooms
Men are typically introduced to porn in high
school, girls are introduced to it by boys
 Women report less interest in buying erotic films,
magazines and rate romantic scenes as more
arousing than explicit scenes



 But women are physically aroused to erotica
Women are 2x as likely to report disgust as
pleasure initially to porn
 Men are 2x as likely to report pleasure as
disgust initially to porn
