1. SEXUAL DYSFUNCTION When a person is frequently unable to experience a normal sexual response, leading to frustration and distress When a person is frequently unable to experience a normal sexual response, leading to frustration and distress Normal: majority in their reference group. Vast cultural differences Normal: majority in their reference group. Vast cultural differences Not all “experts” agree. Historical changes. e.g.: clitoral orgasm only, not vaginal Not all “experts” agree. Historical changes. e.g.: clitoral orgasm only, not vaginal e.g. Victoria era: women who experienced orgasm with their husbands were “sluts” e.g. Victoria era: women who experienced orgasm with their husbands were “sluts”

2. Historical (Individual) Context religion religion trauma (abuse, assault, etc.) trauma (abuse, assault, etc.) homosexual experience homosexual experience alcohol and drug use alcohol and drug use sociocultural factors sociocultural factors stress stress performance anxiety performance anxiety

3. Women – 43% Men – 30% Young Women: mostly psychosocial Old Men: mostly organic Types of dysfunction: Erectile dysfunction (“impotence”): can be primary or secondary Erectile dysfunction (“impotence”): can be primary or secondary premature ejaculation – 29% premature ejaculation – 29% male orgasmic disorder (its opposite) male orgasmic disorder (its opposite)

4. Types: (Cont’d) female orgasmic disorder (primary and secondary) – 25-35% female orgasmic disorder (primary and secondary) – 25-35% arousal disorder (menopause) arousal disorder (menopause) dyspareunia: painful intercourse dyspareunia: painful intercourse vaginismus: spasms of the vagina, making penetration impossible vaginismus: spasms of the vagina, making penetration impossible vulvodynia: chronic irritation, burning, soreness of the vulva, without contact vulvodynia: chronic irritation, burning, soreness of the vulva, without contact vulvar vestibulitis: pain inside labia minora, introitus – by contact (penis, tampon, toy) vulvar vestibulitis: pain inside labia minora, introitus – by contact (penis, tampon, toy)

5. Types: (Cont’d) hypoactive sexual desire: little interest in sex hypoactive sexual desire: little interest in sex males: 16% males: 16% females: 33% females: 33% sexual aversion disorder sexual aversion disorder males: 8% males: 8% females: 21% females: 21%

6. Organic Causes of Erectile Disorder: circulatory problems circulatory problems heart disease heart disease diabetes (38%) diabetes (38%) medications (e.g., for hypertension) medications (e.g., for hypertension) alcohol, short and long term alcohol, short and long term recreational drugs recreational drugs

7. Some causes of painful intercourse or dyspareunia – women:14-15% (vs. males 3%) introitus scars introitus scars vaginal infections vaginal infections STDs STDs allergies (e.g. latex, spermicides) allergies (e.g. latex, spermicides) low estrogen low estrogen hysterectomy hysterectomy uterine or vaginal prolapse uterine or vaginal prolapse

8. Some causes of painful intercourse or dyspareunia – women:14-15% (vs. males 3%) cancer cancer PID (pelvic inflammatory disease) PID (pelvic inflammatory disease) endometriosis endometriosis cysts cysts insufficient lubrication insufficient lubrication not enough foreplay not enough foreplay

9. Some psychological causes: anxiety anxiety fear of sex fear of sex fear of failure fear of failure inability to let go (cognitive) inability to let go (cognitive) spectatoring spectatoring interpersonal problems interpersonal problems depression: interferes with sexual desire and orgasmic capacity depression: interferes with sexual desire and orgasmic capacity antidepressants: ditto antidepressants: ditto

10. performance anxiety performance anxiety spectatoring spectatoring poor communication poor communication prior learning, conditioning, experience, e.g., rapid masturbation, punishment, sexual abuse, rape, witnessing something disturbing (childhood) prior learning, conditioning, experience, e.g., rapid masturbation, punishment, sexual abuse, rape, witnessing something disturbing (childhood) double standard double standard relationship dissatisfaction relationship dissatisfaction problems with sexual orientation problems with sexual orientation stress stress anxiety (pregnancy, body image, smells, loss of control, injury, being judged, rejection, consequences for relationship, STDs, being heard/seen, etc.) anxiety (pregnancy, body image, smells, loss of control, injury, being judged, rejection, consequences for relationship, STDs, being heard/seen, etc.)

11. Biological factors: testosterone deficiencies – very difficult to establish individual optimal levels testosterone deficiencies – very difficult to establish individual optimal levels hyper or hypothyroidism hyper or hypothyroidism temporal lobe epilepsy temporal lobe epilepsy circulatory system pathology circulatory system pathology neurological problems neurological problems Multiple Sclerosis (leads to male orgasmic disorder) Multiple Sclerosis (leads to male orgasmic disorder) inadequate lubrication (leads to dyspareunia) inadequate lubrication (leads to dyspareunia) vaginal infections (leads to dyspareunia) vaginal infections (leads to dyspareunia) STDs (leads to dyspareunia) STDs (leads to dyspareunia) prolapsed uterus (ditto) prolapsed uterus (ditto) cervical cancer (ditto) cervical cancer (ditto)

12. Biological factors (Cont’d): endometriosis and PID (ditto) endometriosis and PID (ditto) diabetes diabetes spinal cord injuries spinal cord injuries antihypertension drugs antihypertension drugs kidney disease kidney disease emphysema emphysema

13. Common Drugs that affect sexual response: antidepressants antidepressants antipsychotics antipsychotics tranquilizers tranquilizers alcohol alcohol heroin heroin morphine morphine cocaine cocaine marijuana marijuana

14. Therapies: behavioural behavioural cognitive restructuring cognitive restructuring couple therapy couple therapyOther: stop-start technique (for premature ejaculation) stop-start technique (for premature ejaculation) numbing spray on penis numbing spray on penis yoga technique: kundalini yoga technique: kundalini masturbation (for female orgasmic disorder) masturbation (for female orgasmic disorder) Kegel exercises (PC muscle) Kegel exercises (PC muscle)

15. Medical Treatments: Viagra, other drugs Viagra, other drugs inject vasodilators in corpora inject vasodilators in corpora surgery, prosthesis surgery, prosthesis Masters and Johnson’s Sex Therapy: acceptance of mutual responsibility acceptance of mutual responsibility sexual dysfunction a couple’s problem sexual dysfunction a couple’s problem no blame attached no blame attached elimination of performance demands and anxiety elimination of performance demands and anxiety sexual intercourse prohibited during the therapy sexual intercourse prohibited during the therapy

16. Masters and Johnson’s Sex Therapy: (Cont’d) education education elements of anatomy and physiologyelements of anatomy and physiology attitude change attitude change increasing communication increasing communication sensate focus exercises: concentrating on pleasuring one small part of the body at a time sensate focus exercises: concentrating on pleasuring one small part of the body at a time prescribing and practicingprescribing and practicing changes in behaviour

17. Therapeutic steps for anorgasmic women: (women who can’t have orgasms) 1. Education, information 2. Self exploration 3. Kegels 4. Self-touching and self-stimulation. Masturbation 5. Assertive thoughts, giving self permission 6. Use of fantasy, books, video, audiotapes 7. Focus on sensations, not on goal 8. Bring in partner. Nondemanding sensate focus exercises – no intercourse 9. Partner stimulates women manually or orally to orgasm following her directions 10. Intercourse when she is ready

18. Biological treatments for erectile dysfunction: Surgery: to unblock vessels that supply blood to penis Hormones: testosterone, if abnormally low (men and women) MIGHT help Injections: muscle relaxants, into corpus cavernosum. Allows blood vessel muscles to relax and blood flows in Suppositories: muscle relaxant into penis Vacuum pump: increases blood flow into penis Penile implants: permanent

19. Biological treatments for erectile dysfunction: (Cont’d) Pills: Viagra (sildenafil) Vasomax (phentolamine) relax blood vessel muscles Spontane (apomorphine) works at brain level to trigger erection Cialis (tadalafil)

20. Biological treatments for erectile dysfunction: (Cont’d) Side effects of Viagra (dose dependent): headaches flushing indigestion nasal congestion visual distortions drug interactions dizziness eye pain hearing loss allergic reactions Vasomax fewer side effects (?) must be bought by prescription, due to danger of heart attacks.

21. Appendix

28. A more recent approach, not involving medical intervention: Researchers interviewed couples who have great sex to glean what factors were important. 1. being present: totally immersed and intensely focused, no distracting thoughts, surrender to the moment 2. authenticity: free to be themselves, open about what they wanted, totally uninhibited 3. intense emotional connection: regardless of duration of relationship, powerful sense of intimacy throughout the sexual encounter 4. communication, expressing their pleasure, verbalizing what they want 5. transcendence: some people experience an altered state of consciousness Some yogic traditions enable these characteristics (kundalini)