Paraphilias - sexual interest other than in copulatory

Paraphilias
Presentation by: Dr. Penny Frohlich
University of Texas at Austin

Definition: According to wikipedia, Paraphilias refers to powerful and persistent sexual interest other than in copulatory or precopulatory behavior with phenotypically normal, consenting adult human partners.


DSM-IV

* 6-months, recurrent, intense, sexually arousing fantasies/sexual urges
* fantasies/urges involve a specific act
* involving:
o non-human objects
o suffering or humiliation of oneself or another
o children or non-consenting persons
* cause significant distress or impairment


Paraphilias

* Fetishes
* Transvestic fetishism
* Voyeurism
* Exhibitionism
* Frotteurism
* Sadism/masochism
* Pedophilia

Fetishes

* Sexual arousal by:
o using or thinking about an inanimate object
o viewing a particular part of the body
o Common items:
+ womens’ clothing (shoe, stockings, underpants, bras)
+ feet
* Characteristics:
o male
o 25% homosexual
* Causes:
o temporal lobe abnormalities
o learned behavior - classical conditioning
+ 5/7 men conditioned to become sexually aroused to a knee length leather boot
+ 3/7 generalized to other shoes (Rachman & Hodgson, 1968)

Transvestites & Transvestic Fetishism

* Sexual arousal by dressing in clothes of the opposite sex
* crossdressing
* Characteristics:
o broad age range
o broad religious affiliation
o well educated
o in committed relationships
o parents
o heterosexual
o began before age 10
* Causes
o Family:
+ positive paternal role model
+ negative maternal relationship
o associated with learning disabilities
o temporal lobe abnormalities

Sex Offenders

* Voyeurism
* Exhibitionism
* Frotteurism
* Preferential Rape Pattern
* Pedophilia
* Psychopathic Sexual Sadism

Courtship Disorders

* Voyeurism:
o “peeping tom”
o sexual arousal by observing nude individuals without their knowledge or consent
o intense urges and recurrent behavior
* Exhibitionism: sexual arousal by exposing genitals to unsuspecting strangers - typically in inappropriate settings
* Frotteurism: sexual arousal by rubbing one’s genitals against others in public
* Preferential rape pattern: prefer rape over consensual sex

Voyeurism

* Characteristics:
o youngest child
o few sisters
o good relationship with parents
o parents with poor relationship
o underdeveloped socially
+ later 1st sexual experience
+ less likely to marry
* Females:
o rare
o peeping fantasies not uncommon (Friday, 1975)

Exhibitionism

* Characteristics:
o almost exclusively male
o timid/unassertive
o undeveloped social skills
o uncomfortable with anger/hostility
o more likely to be raised in puritanical background
* Females:
o do not derive pleasure
o motivation: money (e.g., strippers) or attention (e.g., Marti Gras)

Frotteurism

* Characteristics:
o comorbidity: 79%
o Average number of acts:
+ 849 (Abel et al., 1987)
o in females: molestation secondary to erectile failure, low desire (Sarrel & Masters, 1982)

Sadism & Masochism
* Sadism: sexual arousal by inflicting pain on another
* Masochism: sexual arousal by having pain inflicted upon oneself
* History
o “masochist” (1886) Krafft-Ebing, after Leopold von Sacher-Masoch
o “sadist” (1700s) after Marquis de Sade

Sadomasochism (S & M)

* Major vs minor sexual sadism
* Sadomasochism (S & M)
o pre-determined acts
o activities & themes (Arndt, 1991; Weinberg et al., 1984):
+ flagellation
+ bondage
+ water sports (urophilia, coprophilia, mysophilia)
+ penis and nipple torture
+ master & slave
+ severe boss and naughty secretary
+ queeen and many slavves
+ arrest
+ military training
* Characteristics
o predominantly male
o female: 25% prostitutes
o meet through S & M magazines
o come from all walks of life, SES, educ. etc
o 1/3 heterosexual, 1/3 bisexual, 1/3 homosexual

Major Sexual Sadism

* Seto & Kuban (1996)
o sadistic rapist, non-sadistic rapist, controls
o penile volume changes
o Five films:
+ nonviolent, non-sexual w/ female
+ consensual sex w/ female
+ non-sexual violence against female
+ rape
+ violent rape
* Seto & Kuban (1996) continued
o both types of rapist equally aroused by different types of sex
o controls differentiated between consensual and non-consensual sex
* Temporal lobe abnormalities (Langevin et al., 1988)

Psychopathic Sexual Sadism

* DSM-IV
o sexual sadism
o antisocial personality disorder (ASPD)
* Serial murderer
o arousal from inflicting pain
o arousal from killing
* Characteristics
o Lack of guilt or compassion for victim
o Euphoria during murder
o mentally disturbed, rarely psychotic
* Geberth & Turco (1997)
o 387 serial murders
o 248 sexually assaulted victims
o 68 met criteria for sexual sadism & ASPD
+ childhood aggressiveness
+ childhood antisocial behavior
+ killing involving sexual violence, humiliation, domination and control
+ derived pleasure from killing
o examples: Ted Bundy, Gary Ridgeway

Pedophilia

* Sexual fantasies, urges, or behavior involving children under 14 years old
* prevalence
* Characteristics/Causes:
o 40% homosexual
+ high maternal age
+ low IQ
+ developmental disorder?
o history of childhood sexual abuse (49%) by a male abuser

Development of Paraphilias

* Physiological characteristics:
o higher baseline cortisol, prolactin, body temperature
o stronger cortisol response
o disturbance in serotonin regulation --> OCD
o showed slides of nude male and female children
o pedophiles and controls
o measured penile volume changes
o Results: pedophiles less differentiation between slide types

Treatment of Paraphilias

* 1900 castration, psychosurgery
* Cognitive-Behavioral Therapy - Aversion Therapy
o effective in lowering arousal
o relapse high
* Pharmaceutical
o agents that lower testosterone/produce pharmaceutical castration
o SSRIs

Additional Paraphilias

* Bestiality & zoophilia
* coprolalia
* coprophilia
* klismaphilia
* mysophilia
* necrophilia
* pedophilia
* scoptophilia
* stigmatophilia
* telephone scatologia
* troilism
* urophilia
* kleptomamia
* pyromania
* salirophilia
* somnophilia
* sotophilia

Paraphilia-Related Disorders

* compulsive masturbation
* protracted promiscuity
* dependence on pornography (more common in men)
* dependence on cybersex

Check regarding diagnosing if no distress - with regard to pedophilia etc.


Generalized to:
Family:
Results
pharmaceutical:
Bestiality & zoophilia: sexual arousal through contact with animals
coprolalia: need to hear filthy language to become sexually aroused
coprophilia: need to smell or riew feces to become aroused
klismaphilia: sexual arousal by being given an enema
mysophilia: arousal by filth or filthy surroundings
necrophilia:
scoptophilia: by observing others engaged in sexual intercourse
stigmatophilia: marking body, inserting objects into the body
telephone scatologia: arousal by making obscene phone calls
troilism: arousal by sharing partner and looking on
urophilia: “golden showers” on or watching
kleptomamia; aroused by act of steeling
pyromania: aroused by setting fires, watching fires
salirophilia: injestion of anothers sweet or saliva
somnophilia: having sex with someone who is sleeping
sotophilia: aroused by sight of certain foods.

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Diaphragms

Diaphragms

Diaphragms: Definition

A dome-shaped latex (rubber) cup that is inserted into the vagina before intercourse and covers the cervix

Types of Diaphragms
* Flat spring (flat metal band)
* Coil spring (coiled wire)
* Arching spring (combination metal spring)

Diaphragms: Mechanism of Action
Prevent sperm from gaining access to upper reproductive tract (uterus and fallopian tubes) and serve as holder for spermicide

Diaphragms: Contraceptive Benefits
* Effective immediately
* Do not affect breastfeeding
* Do not interfere with intercourse (may be inserted up to 6 hours before)
* No method-related health risks
* No systemic side effects

Diaphragms: Noncontraceptive Benefits
* Some protection against STDs (e.g., HBV, HIV/AIDS) especially when used with spermicide
* Contain menstrual flow when used during menses

Diaphragms: Limitations

* Moderately effective (6B201 pregnancies per 100 women during the first year of use if used with spermicide)
* Effectiveness as contraceptives depends on willingness to follow instructions
* User-dependent (require continued motivation and use with each act of intercourse)
* Pelvic examination by trained service provider (may be nonphysician) required for initial fitting and postpartum refitting
* Associated with urinary tract infections in some users
* Must be left in place for 6 hours after intercourse
* Supplies must be readily available before intercourse occurs
* Resupply must be available (spermicide required with each use)

Who Can Use Diaphragms
Women who:

* Prefer not to use hormonal methods or who should not use them (e.g., smokers over 35 years of age)
* Prefer not to or should not use IUDs
* Are breastfeeding and need contraception
* Want protection from STDs and whose partners will not use condoms
Couples:

* Who need a temporary method while awaiting another method
* Who need a backup method
* Who have intercourse infrequently
* In which either partner has more than one sexual partner (at high risk for STDs), even if using another method

Diaphragms: Conditions Requiring Precaution (WHO Class 3)
Diaphragms are not recommended unless other methods are not available or acceptable if a woman has:

* A history of Toxic Shock Syndrome (TSS)
* An allergy to rubber or spermicides
* Repeat urinary tract infections (UTIs)
* Uterine prolapse
* Vaginal stenosis
* Genital anomalies

Diaphragms: Who May Require Additional Counseling

* Women whose age, parity or health problems make pregnancy high risk
* Women with physical disabilities or who find it unpleasant to touch their genitals
* Women who do not want any inconvenience
* Couples who want a highly effective method of contraception
* Couples who want a method not related to intercourse
* Couples not willing to use correctly and with each act of intercourse
* Couples who do not have soap and water readily available

Diaphragms: Management of Side Effects
Toxic Shock Syndrome (TSS):

* Examine for signs/symptoms of TSS (e.g., fever, rash, nausea, vomiting, diarrhea, conjunctivitis, weakness, decreased blood pressure and shock).
* If suspected, refer client to center where intravenous fluids and antibiotics are available.
* Give oral rehydration as needed and a non-narcotic analgesic (NSAID or aspirin) if fever is high (> 38EC).
Urinary tract infection (UTIs):

* Treat with appropriate antibiotic.
* If client has frequent UTIs and diaphragm remains her first choice for contraception, advise emptying bladder (voiding) immediately after intercourse.
* Offer client postcoital prophylactic (single-dose) antibiotic. Otherwise, help client choose another method.

Diaphragms: Management of Side Effects continued

* Suspected allergic reaction to diaphragm or spermicide:
* If allergic, help client choose another method
* Pain from pressure on bladder or rectum B Assess diaphragm fit. If current device is too large, fit with smaller device. Follow up to be sure problem is solved.
Allergic reactions, although uncommon, can be uncomfortable and possibly dangerous.

Diaphragms: Management of Side Effects continued
* Vaginal discharge and odor if left in place for more than 24 hours:
* Check for STD or foreign body. If not, advise client to remove diaphragm as early as is convenient after intercourse, but not less than 6 hours after last act.
* If symptoms recur, counsel regarding vaginal hygiene.
* Vaginal lesion caused by diaphragm rim pushing against vaginal wall:
* Temporarily stop use and provide backup method. When healed, check diaphragm fit (may be too large).

Diaphragms: Client Instructions

* Use diaphragm every time you have intercourse.
* First, empty your bladder and wash your hands.
* Check diaphragm for holes by pressing rubber and holding it up to light or filling with water.
* Squeeze small amount of spermicidal cream or jelly into cup of diaphragm.
* To make insertion easier, place small amount of cream/jelly on leading edge of diaphragm or in vaginal opening. Squeeze rim together.

Diaphragms: Client Instructions continued

* The following positions may be used for inserting diaphragm:
* One foot raised up on a chair or toilet seat
* Lying down
* Squatting
* Spread lips of vagina apart.
* Insert diaphragm and cream/jelly back in vagina and push front rim up behind pubic bone.

Diaphragms: Client Instructions continued

* Put your finger in the vagina and feel the cervix (feels like your nose) through the rubber to make sure it is covered.
* The diaphragm can be placed in the vagina up to 6 hours before having intercourse.
* If intercourse occurs more than 6 hours afterwards, another application of spermicide must be put into vagina.
* Additional cream or jelly is needed for each repeated intercourse.
* Leave diaphragm in for at least 6 hours after the last time intercourse occurs. Do not leave it in more than 24 hours after intercourse.
* Vaginal douching is not recommended at any time. If done, it should be delayed for 6 hours after intercourse.
* Remove diaphragm by hooking finger behind front rim and pulling it out. If necessary, put your finger between diaphragm and pubic bone to break the suction before pulling out.
* Wash diaphragm with mild soap and water and dry it thoroughly prior to returning it to container.

When to Consider Emergency Contraception

If a client does not wish to be pregnant, and she:

* forgot to use the diaphragm when she had intercourse
* thinks she may have used the diaphragm incorrectly
* had intercourse more than 6 hours after inserting the diaphragm but did not apply more spermicide
* did not leave the diaphragm in for 6 hours after having intercourse

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Sexual Anatomy & Physiology

Sexual Anatomy & Physiology
Presentation by: Dr. Penny Frohlich
University of Texas at Austin

Female External Genitalia

Vulva: everything that is externally visible (mons pubis, labia majora, labia minora, clitoris, urethral orifice, vaginal vestibule, perineal body)
mons pubis: mound of fatty tissue above the pubic bone
labia majora: large, outer fatty folds of skin tissue
labia minora: inner folds of skin and erectile tissue
clitoris: small, highly sensitive organ
glans: tip of the clitoris
prepuce (clitoral hood): loose-fitting fold of skin covering the clitoral glans
vaginal vestibule: the cleft containing the vaginal and urethral openings
Skene’s glands: group of small mucous glands that open into vaginal vestibule (near urethra)
Bartholin’s glands: two glands that open into vaginal vestibule (on either side of the vaginal opening) - thought to provide some lubrication, may emit a pheromone
hymen: thin mucous membrane partially covering the vaginal opening
perineum: tissue between the genital and anus.

Normal Variations

Female Internal Genitalia
Vagina: tubular organ connecting external genitals with uterus
Grafenberg spot (g-spot):

o mass of erectile and glandular tissue surrounding the urethra just below the bladder
o some women report that simulation to g-spot produces sexual arousal and orgasm

uterus: hollow muscular organ - purpose to nurture developing fetus

cervix: small lower portion of the uterus that projects into the vagina
cervical os: small opening in the cervix allowing passage of fluids between the uterus and vagina
myometrium: layers of smooth muscle comprising the uterus
endometrium: inner lining of the uterus that builds a rich blood supply and sloughs off the lining each month (if conception does not occur)

ovaries: female gonads - containing the immature female reproductive cells
ovum: female reproduce cell
fallopian tubes: thin flexible muscular structures connecting the ovaries with the uterus - passageway for the ovum to travel to the uterus
cilia: tiny hairlike projections that line the fallopian tubes and propel the ovum towards the uterus
fimbriae: fringelike projections that reach out to the ovary to draw a released ovum into the fallopian tube.

Sexual Response
Arteries & Veins
Female Internal Genitalia: Muscles

* Pelvic floor muscles
o Ischiocavernosus: acts to drive blood into the body of the clitoris
o bulbocavernosus: helps to maintain the structure of the pelvic tissue and serves as a vaginal sphincter

Female Internal Genitalia: Nerves
* Sexual arousal: stimulation to tactile and temperature receptors on the genitalia, breasts, etc.
* Orgasm: genital reflex governed by the spinal cord

Male External Genitalia

penis: male copulatory organ
frenulum: underside of the penis, between shaft and glans
glans: enlarged conic structure at the tip of the penis
corona: raised rim or ridge of tissue that separates the glans from the shaft
prepuce (forskin): loose-fitting retractable casing of skin that forms over the glans
smegma: accumulation of secretions on the penile glans from glands of foreskin
circumcision: surgical procedure involving removal of the prepuce
scrotum: skin-covered pouch containing the testes

corpora cavernosa: two large and uppermost cylindrical masses of penile tissue
corpus spongiosum: lower, smaller cyhlindrical mass of tissue in the penis, contains the urethra
crura: tapering part of the corpora cavernosa - forms the connection to the pubic bone
Testes: oval, glandular organs contained in the scrotum - produce sperm, secrete male hormones
spermatic cord: suspends the testes - contains arteries, nerves, veins, vas deferens
seminiferous tubules: tightly packed, convoluted structures in testicles, produce sperm
interstitial cells (Leydig’s cells): located between seminiferous tubules, produce androgens
epididymis: tightly coiled tube lying along the top of each testis - stores spermatozoa
vas deferens: structure that transports spermatozoa from testes to urethra
ejaculatory ducts: short tubes that pass through prostate to urethra - passageway for semen and fluid from seminal vesicles
urethra: tube for transporting urine and semen
seminal vesicles: secretory glands
prostate gland: secretes thin, milky, slightly alkaline fluid, rich in nutrients - into the seminal fluid - these secretions protect spermatozoa from acidic environment (male urethra, vagina)

cowper’s gland: contribute alkaline fluid to semen
Cross-section of the Penis
corpora cavernosa (upper left)
corpus spongiosum (lower right)
sperm: male reproductive cell

spermatogenesis: process of sperm production
spermatozoon: single sperm
spermatozoa: sperm, plural
acrosomal cap: covering of the head of the spermatozoon - contains enzymes that penetrate the outer cover of the ovum

semen: contains:

spermatozoa: sperm, plural
seminal fluid: contains secretions from seminal vesicles, prostate gland, Cowper’s gland, and epididymis

Arteries & Veins
Male Internal Genitalia: Muscles
Male Internal Genitalia: Nerves
Sexual Response Cycle

* Masters and Johnson Four-Stage Model
o excitement
o plateau
o orgasm
o refractory period

Sexual Response Cycle: Excitement

* For both males and females excitement leads to an increase in pulse, heart rate, blood pressure and muscle tension. Similarly both sexes experience increase blood flow to the genitals and nipples.
* In females, the vagina becomes naturally lubricated, lengthens and widens, whilst the labia swell.
* In males, erection of the penis is the most obvious sign of excitment.

Sexual Response Cycle: Plateau

* Further increases in circulation and heart rate occur in both sexes, sexual pleasure increases with increased stimulation, muscle tension increases further.
* At this stage females show a number of effects. The areolae and labia further increase in size, the clitoris withdraws slightly and the Bartholin's glands produce further lubrication.
* Males may start to secrete seminal fluid and the testes rise closer to the body.
* Orgasm is the conclusion of the plateau phase in a release of sexual tension. Both males and females experience quick cycles of muscle contraction of the anus and lower pelvic muscles, with women also experiencing uterine and vaginal contractions.
* Males ejaculate approximately 5-10ml of semen.

Sexual Response Cycle: Resolution

* The resolution stage occurs after orgasm and allows the muscles to relax, blood pressure to drop and the body to slow down from its excited state.
* Generally males experience a refractory period, meaning orgasm cannot be achieved again until time has passed. The penis meanwhile returns to a flaccid state. Females may not experience this refractory period and further stimulation may cause a return to the plateau stage. Otherwise, significant changes may also occur, such as the opening of the cervix and the reduction of blood flow to the genitals and nipples.

Sexual Response Cycle

* Kaplan three-stage model (1974)
o sexual desire
o sexual excitement
o orgasm

Sexual Desire

* Sexual appetite or drive
o sexual fantasies
o masturbation
o seek out, or be receptive to (Basson) sexual activity


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