The Biological Bases of Compulsive Sexual Behavior

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Male Sexual Health
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• Male Erectile Disorder (Erectile Dysfunction)
• Rapid Ejaculation (Premature Ejaculation)
• Compulsive Sexual Behavior (CSB)
• Hypoactive Sexual Desire
• Sexual Aversion
• Male Orgasmic Disorder
• Dyspareunia
• will be covered today

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Male Erectile Disorder (ED)

• More commonly known as erectile dysfunction
• Often a strong biological component
• Partner often misperceives the meaning of the
  situation
• Psychogenic ED is almost always a function of
  anxietysexuality
• The events that created the ED may not maintain
  the ED

Sex at age 90 is like trying to shoot pool with
a rope. George Burns
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ED Definition

• Persistent or recurrent inability to attain or
  maintain an adequate erection
• Prevalence By age 50, 50 of men feel they have
  at least mild ED (Feldman et al. 1994)
• Lifelong vs. acquired
• Generalized vs. situational
• Differential Diagnosis
• Sexual dysfunction due to a general medical
  condition
• Substance-induced sexual dysfunction
• Occasional difficulties with erections

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ED PLISSIT

• P Occasional difficulties with erections is
  normal
• Sex does not equal intercourse
• LI Common ways psychogenic ED gets started
• The link between anxiety and sexual function
• The biology of erections (high risk categories)
• Education for the partner
• SS Challenge unrealistic sexual expectations
• Physician referral
• Vacuum pump, PDE5i, intracavernosal injections
• Increase sexual communication skills
• Help client explore non-coital sexuality

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Premature (Rapid) Ejaculation

• Often confused with unrealistic sexual
  expectations
• Partner often misperceives the meaning of the
  situation
• Rapid ejaculation is almost always a function of
  anxietysexuality
• Usually perpetuated by a snowball dynamic,
  characterized by increasing levels of
  anxietysexuality

A hard-on doesnt count as personal
growth. Evelyn Loeb Except in sex
therapy!
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Premature Ejaculation Definition

• Persistent ejaculation with minimal stimulation,
  and before the person wishes it.
• Differential Diagnosis
• Normal range of sexual functioning
• Occasional problems with rapid ejaculation
• Substance induced sexual dysfunction

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Myths that Perpetuate Rapid Ejaculation

• Most men last for at least 10 minutes
• A good lover lasts until his partner orgasms
• Thrusting alone is enough for most women to have
  an orgasm during intercourse
• Concentrating on something else delays orgasm
• PE is a sign of selfishness
• PE is a sign of a power struggle

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Facts about Rapid Ejaculation

• The average length of sexual intercourse is 2-7
  minutes (Leiblum and Rosen, 1989)
• Expecting simultaneous orgasms is unrealistic
• Most women require clitoral stimulation to
  achieve orgasm
• Concentrating on something else encourages rapid
  ejaculation
• PE is a symptom of lack of familiarity and
  attentiveness to physical cues

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Rapid Ejaculation PLISSIT

• P Occasional difficulties with ejaculatory
  control is normal
• Empower sexuality that works for client and
  partner
• LI Statistics about realistic sexual
  encounters
• Contradicting rapid ejaculation myths
• Providing statistics
• Education for the partner
• SS Start/stop method
• Increasing sexual repertoire
• Increase sexual communication skills

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Compulsive Sexual Behavior (CSB)

• Also known as Hypersexuality, Erotomania,
  Nymphomania, Satyriasis, Hyperphilia, Sexual
  Addiction, Paraphilia
• No agreement in psychological community regarding
  definition, etiology or classification
• Addiction? Impulse control disorder?
• Mood disorder? Obsessive/compulsive disorder?
• Psychosexual developmental disorder?

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CSB Definition

• 1) Recurrent and intense sexually arousing
  fantasies, sexual urges, and behaviors that cause
  clinically significant distress in social,
  occupational, or other important areas of
  functioning
• 2) Not due to another medical condition,
  substance use disorder, or developmental
  disorder. E. Coleman (2003)

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CSB Definition (Cont.)

• Prevelance Approximately 5 of the U.S.
  population Coleman (1992) and Barth Kinder
  (1987)
• Paraphilic vs. Nonparaphilic (Normophilic)
• Paraphilic CSB Pedophilia, Exibitionism,
  Voyerism, Sexual Masochism, Sexual Sadism,
  Fetishism, Transvestic Fetishism, Frotteurism
• Nonparaphilic CSB Conventional sexual behaviors
  taken to an extreme, resulting in clinically
  significant impairment

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CSB DSM Classification

• Paraphilias
• Sexual Disorder NOS
• Differential Diagnosis
• Developmentally normal compulsive sexuality
• Sexual problems and experimentation
• Moral conflicts
• Compulsivity exclusively within a mood disorder
• Persistent genital arousal disorder

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CSB Comorbidity

• Lifetime prevalence
• 70 positive for mood disorders
  Raymond at.al. (2003)
• 50-90 positive for anxiety disorders Raymond
  at.al. (2003
• 50 positive for substance use disorders
• Raymond at.al. (2003)
• High incidence of adult ADHD
• Other sexual compulsivity
  Carnes (1992)
• Higher incidents of child abuse/neglect Coleman
  (2005)

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Carnes Level of Addiction

• Level I Behaviors have general cultural
  acceptance, generally victimless (masturbation,
  pornography, prostitution, anonymous sexual
  encounters)
• Level II Behaviors which are sufficiently
  intrusive as to warrant legal sanctions, but seen
  as nuisance crimes(voyeurism, exhibitionism,
  indecent phone calls)
• Level III Behaviors that break significant
  boundaries designed to defend the vulnerable.
  There is typically little compassion or
  understanding for offenders at this level (child
  molestation, rape, incest)
• Carnes (1992)

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Treatment of CSB

• A continuum of care is available
• self help -gt outpatient care -gt residential
  treatment (forensic facilities)
• Medical treatment
• 12 step programs (Sexual Addicts Anonymous, Sex
  and Love Anonymous, Sexaholics Anonymous)
• Controversial
• Psychotherapy
• Cognitive behavioral therapy
• Psychoeducation regarding healthy sexuality
• Individual, family and group modalities

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Treatment of CSBPLISSIT

• P Giving permission for client to be
  him/herself
• Bond with positive sexuality
• LI Definition of CSB (interference in a major
  life role)
• Discussion of the range of sexual expression
• Explanation of sexually compulsive dynamic
• Differentiation between one partners lack of
  comfort and the others pathology
• SS Techniques for increasing intentional
  choices
• Increase advocacy for core needs met by
  compulsion
• Techniques for increasing sexual communication
• Technologies for limiting access
• Educate/empower the partner

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References

• Barth, R. J. Kinder, B. N. (1987). The
  mislabeling of sexual impulsivity. Journal of
  Sex Marital Therapy, 13(1), 15-23.
• Carnes, P. (1992). Out of the Shadows. Center
  City, MN Hazelden.
• Coleman, E. (2005). Neuroanatomical and
  neurotransmitter dysfunction and compulsive
  sexual behavior. In J. S. Hyde (Eds.), Biological
  Substrates of Human Sexual Behavior (pp.
  147-169). New York, NY American Psychological
  Association.
• Coleman, E. (2003). Compulsive Sexual Behavior
  What to call it, how to treat it? SIECUS Report,
  31(5), 12-16.
• Feldman, H., Goldstein, I., Hatzichristou, D.,
  Krane, R., McKinlay, J. (1994). Impotence and
  its medical and psychological coorelates Results
  of the Massachusetts Male Aging Study. Journal of
  Urology, 151, 54-61.
• Leiblum, S., Rosen, R., eds. (1989). Principles
  and Practice of Sex Therapy Update for the
  1990s. New York, NY Guilford Publications.
• Raymond, N. C. (2003). An approach to
  pharmacotherapy of compulsive sexual behavior.
  SIECUS Report, 31(5), 17-18.

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Recommended Reading

• Carnes, P. (1992). Out of the Shadows. Center
  City, Minnesota Hazelden.
• Kaplan, H. S. (1989). How to Overcome Premature
  Ejaculation. New York ,NT Brunner/Mazel, Inc.
• Metz, M. E., McCarthy, B. W. (2003). Coping With
  Premature Ejaculation. Oakland, CA New Harbinger
  Publications.
• Metz, M. E., McCarthy, B. W. (2004). Coping With
  Erectile Dysfunction. Oakland, CA New Harbinger
  Publications.
• Zilbergeld, B. (1999). The New Male Sexuality.
  New York, NY Bantam Books.