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CCMH521wk2Chapter6SexualityandMentalHealth.docxChapter 6 Sexuality and Mental Health
Sex is virtually all in the head anyway.
—John Cloud (2010)
Sexuality and mental health have a dynamic, bidirectional relationship, in which changes in one area directly impact the other (Bitzer et al., 2008; Levine, 2009). Because sexuality is such a central part of people’s lives, there are many mental health-related factors and influences on our sexuality, including how we choose to think, feel, and behave sexually. This chapter delves deeper into the intersections between sexuality and mental health. After reading this chapter, readers will be able to do the following:a.Understand common processes involved in sexual decision-makingb.Describe the impacts of mental health disorders and substance abuse and dependence on sexual functioningc.Understand the diagnostic criteria for sexual dysfunctions that clients may experienced.Identify the impact of sexual trauma on sexuality and sexual functioning
Sexual Decision-Making
Although sex is often portrayed in the American media as spontaneous, passion- and lust-driven, and without much forethought or planning, people actually engage in significant decision-making processes to help them consider their sexual behaviors, attitudes, and activities, including when to have sex and what kind of sex to have. While some of those thoughts, feelings, and behaviors act at an unconscious level, many sexuality-related decisions are made through intentional processes. In this section, we explore the processes through which people make decisions with regard to their sexual activities. These influences are important for counselors to understand because clients’ confidence in their sexual decision-making abilities may impact their overall sense of satisfaction and confidence with regard to their sexual functioning. There is not one decision-making process that everyone uses in deciding whether to engage in sexual behaviors, and if so, in which sexual behaviors they want to engage (Abraham & Sheeran, 1993; Christopher & Cate, 1984; Juhasz, 1975; Oswalt, 2010). Many factors impact people’s decisions about sex, and this section reviews a number of the factors that have been identified in previous research (Oswalt, 2010).
Relational Concerns
Relational concerns, including the amount of love and connection in a relationship, are an important factor in people’s decisions whether to engage in a particular sexual activity (Browning, Hatfield, Kessler, & Levine, 2000; Christopher & Cate, 1984; Oswalt, 2010). How much people love and like their partners, partners’ feelings toward each other, their level of relational commitment, the length of their relationship, and their thoughts of continued romantic involvement with their partners are all relevant relational concerns and impact decisions about engaging in sexual activities (Christopher & Cate, 1984; Oswalt, 2010).
Social Norms and Pressure
Peer pressure and family expectations also impact sexual decision-making. If peers are engaging in sexual activities, then adolescents may be more likely to engage in those same activities (Romer et al., 1994; Rosenthal, Lewis, & Cohen, 1996). What people think that their peers are doing, especially in adolescence, impacts which sexual activities they are more likely to consider engaging in. Also, family
expectations and history impact sexual decision-making (Paul, Fitzjohn, Herbison, & Dickson, 2000). The impacts of social pressure and norms are most pronounced during adolescence but often continue to young adulthood (Regan & Dreyer, 1999).
Concerns About Risks Associated With Sexual Activity
Many sexual activities carry some risks, and concern about these risks is another factor in sexual decision-making. Sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV), and pregnancy are common concerns and risks in having unprotected sex (Levinson, Jaccard, & Beamer, 1995; Oswalt & Wyatt, 2013).
Developmental Stage
Three groups of researchers (Oswalt, 2010; Randolph & Winstead, 1988; Sanderson & Cantor, 1995) have all found that people who are more focused on their own identity (i.e., during the identity vs. role confusion stage) choose to engage in sexual activities for different reasons than people who are more focused on creating intimacy (i.e., during the intimacy vs. isolation stage). In other words, sexual decisions seem to be made for different reasons dependent on the current developmental processes at play.
Amount and Quality of Previous Sexual Experience
The number of previous sexual partners someone has had also has been shown to impact sexual decision-making. Christopher and Cate (1984) found that people who have had only one sexual partner choose to engage in sexual activities most strongly because of relational reasons (e.g., out of affection and to move toward a future with their partner), while people who have had more than one sexual partner engage in sexual activities most strongly because of sexual arousal and receptivity. Other researchers have found a similar relationship between increases in the number of sexual partners and increases in the likelihood of engaging in casual sex (Mikach & Bailey, 1999; Ott, Millstein, Ofner, & Halpern-Felsher, 2006). The quality of previous sexual experiences also matter; if someone has had positive past experiences, then she or he is more likely to engage in the future and vice versa. However, there is not a perfect correlation as might logically be expected based on the quality of past sexual experiences. People who have experienced past sexual trauma would be expected to not engage or less frequently engage in sexual activities; however, there is not a uniform response for people with a history of sexual trauma (Briere & Runtz, 1987).
Expectations for Physical Pleasure
Societal norms hold that men are primarily motivated to engage in sexual activities in order to experience physical pleasure. Women are often not thought to hold physical pleasure as such a high priority, and some researchers have found that this factor is more important for males (Browning et al., 2000; Hill & Preston, 1996). However, other researchers have found that both males and females desire the physically pleasurable aspects of sex (Oswalt, 2010; Randolph & Winstead, 1988; Rosenthal et al., 1996; Traeen & Kvalem, 1996; Wyatt, 1997). While it is not clear if there are differences between the sexes, it is clear that physical gratification and pleasure of sexual activities impacts sexual decision-making. Of course, not all people believe that sex will be a pleasurable experience, and people also may hold negative expectations about the physical sensations (e.g., pain) that they may experience during sexual activities. Some people experience pain during intercourse (e.g., dyspareunia), and some females may begin to experience pain during intercourse as they go through menopause (Dennerstein, Dudley, & Burger, 2001). For these people, negative expectations about pain during sexual activities factors into their sexual decision-making.
Future Plans and Goals
Some adolescents and college students choose not to engage in some sexual activities because they would impact some of their future plans and goals for themselves and their future families (Monsen, Jackson, & Livingston, 1996; Moore & Davidson, 2006; Oswalt, 2010; Young, Denny, & Spear, 1999). Similarly, committed partners may engage in specific sexual activities (including the use and non-use of birth control methods) based on their plans to try to have or to not have children, and partners may talk about whether or not they would like to have a baby in the near future and make sexual decisions regarding type of sexual activities and whether they will use birth control means (Frost & Darroch, 2008; Zolna, Lindberg, & Frost, 2011).
Biological Sex
Biological sex has also been found to impact sexual decision-making (Browning et al., 2000; Christopher & Cate, 1984; Hill & Preston, 1996; Oswalt, 2010; Randolph & Winstead, 1988). For example, Oswalt (2010) investigated differences between males and females in the above factors of sexual decision-making and found differences between all factors except for relational concerns. Females had higher scores than males on concern about risks associated with sexual activity, future plans and goals, and developmental stage, and males had higher scores than females in social norms and pressure, expectations for physical sensation, and amount of previous sexual experience in Oswalt’s sample of college students.
Celibacy and Abstinence
While most people choose some degree of sexual activity, other people make sexual choices for abstinence and celibacy (Abbott, 2000; Sobo & Bell, 2001). Approximately 1% of people choose to be celibate over the course of their lifespans, and many people experience periods of abstinence in their lives (Siegel & Schrimshaw, 2003). Celibacy is defined here as being permanently single across the lifespan, and abstinence is used for the choice of not engaging in oral, vaginal, or anal sex for a period of time. The time periods of abstinence vary depending on the person (i.e., some choose abstinence before being in a committed relationship and/or marriage and some choose abstinence during or after being in a committed relationship), and around one-sixth of 18 to 29 year olds (Laumann et al., 1994; Leigh, Temple, & Trocki, 1993) and around one-third of 60 to 69 year olds (Leigh et al., 1993; Marsiglio & Donnelly, 1991) have been sexually inactive over the past year. Donnelly (1993) found that sexual inactivity was correlated with lower quality of sexual relationship, little to no shared activities with partner, and having children; and Donnelly, Burgess, Anderson, Davis, and Dillard (2001) found that shyness, difficulty relating to others, and negative body image were related to abstaining from sexual relationships. In addition, some people have received biological or medical diagnoses (like HIV) that lead people to choose abstinence, though not all who have received such a disorder choose abstinence (Carey, Carey, Maisto, Gordon, & Vanable, 2001).
Celibate individuals, on the other hand, are not sexually inactive because of these difficulties; they purposefully choose to be single and to not engage in partnered sexual activities (Sobo & Bell, 2001). While many people might think of clergy when thinking about celibate people, many lay people are also celibate. People across history have chosen to be celibate for different reasons including sociopolitical, personal, and/or religious reasons (Abbott, 2000; Sobo & Bell, 2001). Some, such as Joan of Arc, choose celibacy to make a sociopolitical statement and to move toward societal change. Others have chosen celibacy because of personal reasons such as controlling sexual energies or not making attachments associated with sexual partnerships. Some religious orders demand celibacy as part of the vows to become a leader in the religious community, and many cultures have had shamans also practicing celibacy for spiritual reasons (Abbott, 2000; Sobo & Bell, 2001). When working with a client who is celibate or abstinent, it is important not to immediately assume a reason for celibacy or abstinence.
Summary
There are many factors that impact how people make decisions about their sexual activities and experiences, and these factors do not uniformly impact everyone’s sexual decision-making. People make sexual decisions for varying reasons and are affected by their internal rationale and by their social groupings to various degrees. Age and developmental level, amount of sexual experience, love and connection in a sexual relationship, and amount of current desire for children have all been shown to directly correlate with the likelihood of engaging in sexual activities. At the same time, sexual activities require some degree of choice (except in the cases of rape and sex when inebriated) and decision-making. Another influence on sexual decision-making is found in a person’s overall mental health, which may be impacted by the presence of mental health symptoms or disorders, which is addressed in the next section.
Sexual Implications of Mental Health Disorders
When people develop mental health symptoms—such as depression, anxiety, psychosis, or cognitive problems—there are often corresponding changes in their sexual functioning (Davison & Huntington, 2010; Dobkin, Leiblum, Rosen, Menza, & Marin, 2006) and their romantic relationships (Shaver, Schachner, & Mikulincer, 2005). Mental health symptoms also can have indirect impacts on sexual functioning. For example, depression is connected to self-esteem (Cheng & Furnham, 2003), which is related to sexual activities and frequency (Ethier et al., 2006). At the same time, sexual changes can impact relationships and mental health symptoms (Al-Azzawi & Palacios, 2009; Briere & Runtz, 1987). Overall, mental health and sexuality are intimately connected. This section reviews some sexuality-related implications of the major categories of mental health disorders.
Anxiety Disorders
Anxiety disorders make up the most common mental health disorder category, with about 29% of Americans expected to receive an anxiety diagnosis in their lifetime (Kessler et al., 2005). Anxiety can impact sexuality by increasing or decreasing blood flow to the vagina, relationship intimacy, and sexual satisfaction and can lead to sexual difficulties (Bodinger et al., 2002; Déttore, Pucciarelli, Santarnecchi, 2013; Norton & Jehu, 1984). On the other hand, sexual concerns often cause anxiety (Barlow, 1986; Rowland & Incrocci, 2008). Performance anxiety is common among people with sexual arousal problems and orgasm difficulties for both females and males, while low sexual desire among men and women has been connected to higher levels of anxiety (Rowland & Incrocci, 2008). Sexual dysfunctions are more likely for people with anxiety disorders than for people without a mental health disorder in that 50% of people diagnosed with obsessive-compulsive disorder and 64% of people diagnosed with generalized anxiety disorder had a sexual dysfunction compared to 30% of people without a diagnosis (Kendurkar & Kaur, 2008).
When people feel anxious, the acute stress response activates hormones that increase blood pressure and volume, slow down digestion, decrease pain, increase vigilance and awareness, and alter their cognitive processes (Charmandari, Tsigos, & Chrousos, 2005). These changes help the body to respond to the stressful stimuli. When the body continues to be anxious, it will work to maintain higher alertness, awareness, and vigilance by focusing blood toward the stressed body sites, continuing to inhibit digestion and causing hormonal challenges in the body. When we only experience acute stress for a short period of time, our bodies are able to return to a normal state with little to no problems. However, prolonged stress can lead to chronic physiological and behavioral problems (Charmandari et al., 2005).
Low levels of anxiety actually can improve sexual arousal through increased blood flow and volume in the genital areas and increased alertness. Higher levels of anxiety lead to moving the blood away from the genitals to more stressed areas of the body, which can lead to sexual problems. Physiologically, the problems can include decreases in erectile rigidity and volume or in vaginal lubrication and blood flow, which lowers sexual functioning and satisfaction. The decrease in vaginal lubrication and blood flow can even lead to pain during sex (Rowland & Incrocci, 2008). Anxiety can also decrease interpersonal intimacy by increasing emotional reactivity, which can lead to relational conflict and distress (Wei, Vogel, Ku, & Zakalik, 2005).
Sexual problems, including but not limited to sexual dysfunctions, can also lead to increased anxiety. Women who have experienced pain during sex have reported fear and anxiety about it happening again. Likewise, men with erectile problems often feel anxious about experiencing them again in the future. There can be a negative cycle between sexual problems and anxiety, and it is important for counselors to be aware of this and to work to reduce anxiety in clients with sexual problems. Systematic desensitization, sex education, relationship counseling, and specific anxiety treatments are recommended for consideration in these cases.
Mood Disorders (Depressive and Bipolar Disorders)
Making up the second most common category of mental health disorders are the mood disorders, which impact approximately 21% of people over the course of their lifetimes (Kessler et al., 2005). Mood disorders contain two different categories in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) put out by the American Psychiatric Association (American Psychiatric Association; 2013a). In the previous edition of the DSM, these categories were combined into one category of mood disorders, and researchers have not always separated depressive and bipolar diagnoses from each other. Part of why mood disorders are looked at together is because of the similarity of the disorders and the potential difficulty in differential diagnosis among mood disorders. The foundational components of mood disorders are the three mood episodes (i.e., depressive, manic, and hypomanic episodes), and the main diagnostic difference between major depressive disorder and bipolar I or II disorder is the lifetime history of a manic or hypomanic episode (American Psychiatric Association, 2013a). Because someone with a bipolar diagnosis can be experiencing a depressive episode and have very similar symptoms and experiences as someone diagnosed with major depressive disorder, it is important to understand the most recent mood episode when considering current mood implications for sexuality. Depressive and manic episodes impact sexual functioning and decision making differently, and people with either type of mood disorder commonly experience sexual problems (Dell’Osso et al., 2009; Mazza et al., 2009).
Manic episodes are typically brief (i.e., less than 2 weeks) periods of hyperarousal and hyperactivity compared to a baseline mood state for an individual (American Psychiatric Association, 2013a). A common characteristic of mania is engaging in higher-risk behaviors, including adventurous and/or aggressive behaviors, excessive spending, and more frequent sexual activities. In a manic episode, people may engage in sexual activities more frequently or with more partners, and in fact, these behaviors are a part of the diagnostic criteria for bipolar I disorder (American Psychiatric Association, 2013a). Thus, manic episodes may increase sexual expression and activity (Dell’Osso et al., 2009; Mazza et al., 2011). There are few research studies investigating the sexual implications of being in a manic episode (Damian & Miclutia, 2013), which is possibly due to a short duration and small percentage of people who receive treatment during a manic episode. However, Mazza et al. (2011) found a difference in the desire for and frequency of sexual behaviors between people in a manic episode and people in a hypomanic episode. In another study in Turkey, women with a bipolar diagnosis reported lower usage of contraceptives when compared with women with a depressive, schizophrenic, or no diagnosis (Bursalioglu, Aydin, Yazici, & Yazici, 2013).
People who have been diagnosed with bipolar disorder may be prescribed medications to stabilize their mood, as well as antidepressants. Both mood stabilizers and antidepressants have been found to have negative side effects for sexual functioning (Clayton et al., 2002; Modell, Katholi, Modell, & DePalma, 1997; Smith, O’Keane, & Murray, 2002), and some antidepressants have been found to induce sexual dysfunction (Gregorian et al., 2002). Selective serotonin reuptake inhibitors (SSRIs) are a commonly prescribed class of antidepressants and have a strong documentation of negative sexual side effects. Modell et al. (1997) found that 73% of patients on an SSRI had at least some degree of sexual side effects including decreased desire, arousal, and frequency and duration of orgasm, while only 14% of patients on Bupropion had negative side effects (77% reported positive sexual side effects). While there are many considerations for medical doctors to prescribe an antidepressant, SSRIs have the worst prevalence and severity of antidepressants. On the other hand, mood stabilizers as a class and lithium in particular do not tend to have negative sexual side effects and may even help negate some of the sexual side effects of antipsychotics (Nagaraj, Nizamie, Akhtar, Sinha, & Goyal, 2004).
Depressive episodes can have negative sexual implications as well (Baldwin, 2001; Bancroft, Janssen, Strong, & Vudadinovic, 2003; Clayton, 2002; Kennedy, Dickens, Eisfeld, & Bagby, 1999), and 76% of people diagnosed with major depressive disorder also reported sexual dysfunction in one study (Kendurkar & Kaur, 2008). Depressive symptoms include low energy, sluggish feeling, apathy, and below their average interest level in common activities (American Psychiatric Association, 2013a). Just as people experiencing depressive symptoms have reduced energy and interest in their average activities, they also may lose interest in or desire for sexual activities. Sexual dysfunctions are commonly associated and experienced with depressive symptoms (Clayton, 2002; Dunn, Croft, & Hackett, 1999; Kennedy et al., 1999). Sexual arousal, desire, and orgasm are all negatively impacted by depressive symptoms. When antidepressants are used for treatment of depression, the sexual dysfunction can increase in severity (Clayton, 2002), and sexual dysfunction can start from use of some antidepressant medications (Kennedy et al., 1999; Montgomery, Baldwin, & Riley, 2002; Nurnberg et al., 2003; Salerian et al., 2000). Thus, people with depressive symptoms who are taking antidepressants can receive a double dose of negative sexual implications. Counselors can educate clients about the possible etiologies for their sexual difficulties when they are experiencing depressive symptoms. However, not all antidepressants cause negative side effects (Modell et al., 1997), and clients should consult with their medical doctor about any concerns with their medications. For clients who most benefit from SSRIs for their depressive symptoms, sildenafil has been found helpful for increasing arousal, orgasm, and overall sexual satisfaction (Nurnberg et al., 2003; Salerian et al., 2000).
Case Illustration 6.1
Shirley, a Client With Depressive and Sexual Concerns
Shirley is a 36-year-old female who presents to counseling with recurrent depression, a recent breakup from her partner of 10 years, and mild anxiety. She has been experiencing depressive symptoms for almost a year, though the recent breakup is what prompted her to make an appointment for counseling. On intake, she said that she experienced depression first in her early twenties and again later in her twenties. Over the past year, she has said that she has had decreased interest and pleasure, weight gain, trouble sleeping, fatigue, and difficulty concentrating. She has been able to work on a consistent basis, though she has used all of her sick days for the year on days when she felt like she could not get out of bed. Shirley feels worthless and that life does not have meaning, and some thoughts of ending her life have occurred recently, especially after her romantic relationship ended. She said that she used to enjoy the relationship and sex, though that changed roughly a year ago. The couple started to have some unresolved conflict that kept reoccurring, and Shirley stopped being sexually responsive because she did not want to have sex about 10 months ago. Shirley tried to engage in sexual activities on 3 or 4 occasions in the past 8 months, though she was not aroused or mentally engaged when they tried. She is concerned that she will never want to have sex again and will not be able to find or maintain another romantic relationship.
Questions for Reflection and Discussion:1.What impact do you think Shirley’s mental health and sexual concerns have on each other?2.How serious do you think Shirley’s sexual concerns are? What prognosis would you give for Shirley?3.What recommendations or treatment plan would you have for Shirley?4.How would your treatment goals address both her sexuality concerns and her mental health symptoms?
Psychotic Symptoms
Psychotic symptoms can be a part of several different diagnoses including major depressive disorder, bipolar I disorder, schizophrenia, and schizoaffective disorder. Medications are almost always a part of treatment plans when psychotic symptoms are present (Seligman & Reichenberg, 2007), though these medications often have sexual side effects (Baggaley, 2008; Smith et al., 2002), which can compound the other impacts that psychotic symptoms can have on people’s sexual functioning and health. People with psychotic symptoms, especially with symptoms of schizophrenia and schizoaffective disorder, often also have relational difficulties including difficulty with emotional processing, social cues, and vocal emotional tones (Kern, Glynn, Horan, & Marder, 2009; Sergi et al., 2007). It can be difficult to clearly comprehend what people are trying to convey because of difficulty with understanding facial expressions, tone of voice, and other body language. People with psychotic symptoms also may have a hard time differentiating between hallucinations or delusions with reality when experiencing active symptoms. This can lead to relational conflict and difficulties in being intimate. In fact, many people with schizophrenia actually are more troubled by their difficulty sexually than with other problem areas (Lambert et al., 2004).
Antipsychotic medications often make sexual difficulties worse. These medications are typically sedatives to decrease the amount of hallucinations and delusions, and they also inhibit motivation and reward and decrease blood flow from the peripheral parts of the body. This means that antipsychotic medications can lead to arousal and orgasm problems, and they also may decrease libido (Baggaley, 2008). Because of the sexual side effects of antipsychotic medications and sexuality being an important concern for many people with schizophrenia, Baggaley (2008) suggested to consider not taking antipsychotic medications to improve sexual functioning and overall treatment adherence, taking a different antipsychotic that is less likely to have sexual side effects, or to add another medication to mitigate the sexual side effects.
Substance Abuse and Sexuality
Substance abuse is another potential influence on sexuality. Substance abuse and addictions impact romantic relationships (Seligman & Reichenberg, 2007), and some of the effects of substance intoxication can impact sexual arousal and performance. When dependence on a substance develops, the addiction may become a prominent part of the person’s life, thereby decreasing the importance of other areas in life, including sexual relationships. As such, it is not surprising that there is also significant comorbidity between substance abuse and dependence and sexual dysfunctions (Johnson, Phelps, & Cottler, 2004).
Rates of substance use and abuse remain high. According to the 2013 U.S. Substance Abuse and Mental Health Services Administration’s (SAMHSA, 2014) national survey, approximately 24.6 million Americans, representing 9.4% of the population 12 years and older, used illicit drugs in 2013. Furthermore at the time of the survey, 60.1 million Americans (22.9%) binge drank alcohol in the past 30 days. Given these high rates, it is important for counselors to understand the intersections between substance abuse and sexuality. Substance use occurs with sexual activities in both healthy and unhealthy ways. For example, some people may report that substance use can enhance their sexual expression and satisfaction, or substance use might negatively impact sexual performance, functioning, and relationships. A thorough assessment is often needed to determine if substance use is positively or negatively impacting sexual expression, satisfaction, and relationships. It can be much easier to see the negative consequences of substance abuse and dependence upon sexuality.
Illicit drugs can impact the dopamine levels in the mesocorticolimbic system and initiate the brain’s reward system, which typically leads to pleasurable feelings and other various changes, depending on the drug of use (Feltenstein, & See, 2008). With substance dependence, the brain has been so used to the dopamine and stimulation to the reward system of the brain that there is actually pain in the absence of the substance leading to changes in the brain’s stress system and other changes in the brain that differ according to the substance (Feltenstein & See, 2008). When this happens, people dependent on a substance tend to have many behavioral changes that have a negative impact on their social, romantic, and vocational aspects of life (Seligman & Reichenberg, 2007). It is not uncommon for substance dependence to lead to stealing money from loved ones, skipping important family and social events, and other negative interpersonal interactions. Also with substance dependence, there often is some degree of cognitive distancing from other aspects of life other than the substance and its use (Fisher & Harrison, 2009).
In romantic relationships, there are commonly communication problems, hostility, and disapproval when a partner has substance use problems (Jacob, Ritchey, Cvitkovic, & Blane, 1981). Positive communication is a hallmark with relationship satisfaction (Litzinger & Gordon, 2005) and is connected to relationship satisfaction and sexual satisfaction (Byers, 2005; Litzinger & Gordon, 2005). Negative communication and interaction patterns and cycles in the couple are evident in couples that stay together when one or both are dependent on substances (Copello, Velleman, & Templeton, 2005; Epstein & McCrady, 1998). Overall, marital dissatisfaction is higher when there is substance dependence or abuse (Homish & Leonard, 2007), and relationship satisfaction is significantly connected with sexual activity and sexual satisfaction (Byers, 2005; Litzinger & Gordon, 2005; Santtila et al., 2007). In summary, there is typically lower relational and sexual satisfaction and decreased sexual activity with substance abuse and dependence.
Also, there is a significant correlation between sexual dysfunction and substance abuse. Depressant substances decrease awareness, blood flow, and breathing, all of which can decrease sexual experience and performance in substance intoxication. Substance abuse has been linked to higher rates of sexual dysfunction (Carnes, Murray, & Charpentier, 2005; Horvath, Calsyn, Terry, & Cotton, 2007; Johnson et al., 2004). People who use illicit drugs or alcohol have been shown to have a significantly higher amount of sexual dysfunction than people who do not use illicit drugs or alcohol (Johnson et al., 2004), and approximately 40% of people with sexual addictions also reported substance abuse (Carnes et al., 2005). Thus, there is a clear connection between sexual problems and substance abuse, both in relational and physiological aspects.
Sexual Dysfunctions
Male and Female Sexual Dysfunctions in the DSM-5
The Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5; APA, 2013a) includes an entire category designated for sexual dysfunctions composed of ten total disorders, of which four are exclusively for males and three are exclusively for females. The sexual dysfunctions are related to sexual arousal and desire (erectile disorder, male hypoactive sexual desire disorder, and female sexual interest/arousal disorder), pain (genito-pelvic pain/penetration disorder), orgasm (delayed ejaculation, premature [early] ejaculation, and female orgasmic disorder), and not otherwise specified (substance/medication-induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction). There are some recent changes from the Diagnostic and Statistical Manual of Mental Disorders-4-Text Revision (DSM-IV-TR) to the DSM-5 in the names and criteria of sexual dysfunctions, and the name changes are represented in Table 6.1 (Zucker, 2013).
Table 6.1 Recent Name Changes of Sexual Dysfunctions
For males, there are four specific sexual dysfunctions, erectile disorder, male hypoactive sexual desire disorder, delayed ejaculation, and premature (early) ejaculation. The first two are related to arousal and desire, and the latter two are related to orgasm. The criteria for all four disorders include the symptoms being present for the vast majority (75% to 100%) of partnered sexual activity for at least the past six months and causing clinically significant distress (American Psychiatric Association, 2013a). Each of these can be lifelong (i.e., where the symptoms have always been present) or acquired (i.e., having sexual dysfunction after previously experiencing significantly more sexual functioning) and can be generalized (i.e., in all circumstances) or situational (i.e., only in certain circumstances). Therefore, clients who meet the criteria for these disorders may seek counseling to help relieve the distress and/or symptoms that they are experiencing. Erectile disorder is appropriate for males who have marked difficulty obtaining or maintaining an erection or have had a marked reduction in the rigidity of erection, and male hypoactive sexual desire disorder is appropriate when males have no or low sexual or erotic thoughts, fantasies, and desires. Delayed ejaculation is appropriate when there is a marked delay, infrequency, or absence of ejaculation during partnered sexual activity, and premature (early) ejaculation is appropriate when ejaculation happens within a minute of penetration and before the male wishes.
In past research, the most common male sexual dysfunction has been premature ejaculation, which is estimated to impact around 30% of males at some point in their lives (Laumann et al., 2009; Waite, Laumann, Das, & Schumm, 2009) and can lead to relationship challenges (Graziottin & Althof, 2011; Kempeneers et al., 2012). The new diagnostic criteria that came out with the fifth edition of the DSM now specifies that premature ejaculation must occur within one minute of penetration. The APA (2013a) noted that this will drastically reduce the people diagnosed with this disorder, due to the time specifier, and they speculated that only about 1% to 3% of men will now be diagnosed with premature ejaculation. In terms of treatment, Masters and Johnson (1970) developed a behavioral technique to help treat premature ejaculation called the “squeeze technique,” where the partner repeatedly stimulates the male’s penis until he is close to orgasm and then squeezes the penis with thumb and fingers until the male calms down to help condition a delay in orgasm. More recently, a treatment combination of cognitive and sex therapies with medications has been recommended for premature ejaculation (Barnes & Eardley, 2007).
Erectile disorder is the most or second-most common male sexual dysfunction, with around 13% to 21% of 40- to 80-year-old males and 40% to 50% of 60- to 70-year-old men experiencing this condition (American Psychiatric Association, 2013a; Porst et al., 2013). The lifelong prevalence of erectile disorder is unknown, although the chance of experiencing erectile disorder increases with age (American Psychiatric Association, 2013a; Laumann et al., 2009; Lindau et al., 2007). Some people call the difficulty of achieving or maintaining an erection, “impotence,” a term that typically carries a negative connotation for the male. Usually, there is a physiological rationale for this condition, and it is recommended that men with this condition consult with their medical doctor (King & Regan, 2014; Porst et al., 2013). The symptoms could be due to circulatory, prostate, neurological, injury, hormonal, or substance use reasons (Porst et al., 2013). It is important to assess for the possibility of substances, including medications, causing the symptoms (which would be more appropriately diagnosed as substance/medication-induced sexual dysfunction) and working with the client’s physician in cases where the client wants help with erectile disorder symptoms. Medication therapy for erectile disorder is the most common form of treatment (Porst et al., 2013). In cases where it is more of a psychological cause for erectile difficulties, sensate focusing exercises are often the recommended treatment (King & Regan, 2014; Masters & Johnson, 1970). Stress, depression, and performance anxiety can impact erections, and allowing couples to not focus on performance and to explore what sexual activities and touches are pleasurable can be helpful in achieving and maintaining erection (Berry & Berry, 2013; King & Regan, 2014).
The frequency and prevalence of male hypoactive sexual desire disorder has been shown to vary across cultures and ages. Laumann et al. (2009) found that 18% of men in the United States had a lack of sexual interest over the past year and that 3.3% frequently had a lack of sexual interest. The APA (2013b) reported that 12.5% of Northern European men and 28% of Southeast Asian men have low sexual desire. In clinical populations, around half of couples experience low sexual desire, although it tends to be higher in females than males, and males with hypoactive sexual desire tend to be older than females with low sexual desire (Segraves & Segraves, 1991). While developmental history, current relationship(s), stress, and medical conditions may impact sexual desire, it seems that the main factor for most males is a lack of erotic thoughts (Carvalho & Nobre, 2011; Rubio-Aurioles & Bivalacqua, 2013). Knowing the etiology of the issue (psychological, relational, or physiological) and orienting treatment accordingly is recommended (Rubio-Aurioles & Bivalacqua, 2013).
Delayed ejaculation has a low frequency of occurrence, and it is estimated to affect less than 1% of men overall (American Psychiatric Association, 2013a). The main cause of delayed ejaculation is thought to be based on psychological factors and not physiological factors (Corona et al., 2006; Rowland, Keeney, & Slob, 2004; Rowland, 2005). Rowland et al. (2004) found that males with delayed ejaculation had very similar physiological responses to males with and without other sexual dysfunctions, though their subjective, internal arousal was reported lower than other males. Corona et al. (2006) also had similar conclusions, though they also admitted that some medications can delay ejaculation, specifically selective serotonin reuptake inhibitors (SSRIs), which are commonly prescribed anti-depressants. Because of this and increases in the prevalence in use of SSRIs, it may be that the frequency of delayed ejaculation increases (Corona et al., 2006). There are not currently any medical treatments for delayed ejaculation, and treatment can be difficult (Hartmann & Waldinger, 2007). Behavioral techniques of guided stimulation moving from solo ejaculation toward partnered, typically intravaginal, ejaculation, cognitive-behavioral focus in changing inhibitory beliefs and increasing internal sexual arousal, and systemic approaches to shifting and enhancing the couple’s erotic potential and patterns are recommended approaches to treating delayed ejaculation (Hartmann & Waldinger, 2007).
While there is not a specific male sexual pain disorder, some men do experience pain during sexual activities (Davis, Binik, & Carrier, 2009). There is almost always a physiological reason for the pain, and it is important to consult a physician for possible prostate or urological problems (Davis et al., 2009).
For females, the frequencies of the three gender-specific sexual dysfunctions are not clearly determined, and the APA (2013a) openly stated the lack of evidence and the large possible differences in prevalence in different cultures. According to Laumann et al. (2009), the most common female sexual dysfunctions are lack of sexual interest (33%) and lubrication difficulties (22%), which is characterized in the DSM-5 as the sexual dysfunction of female sexual interest/arousal disorder (American Psychiatric Association, 2013a). Laumann et al. found that 33% of women experienced low sexual interest and 22% experienced lubrication difficulties in the past year, while about 10% and 6%, respectively, experience them on a regular basis. It is uncommon for couples to show comorbidity of another sexual dysfunction (notably orgasm, pain, and erectile dysfunctions) with female sexual interest/arousal disorder (Hertlein, Weeks, & Gambescia, 2007). In clinical populations, around half of couples report low sexual desire in at least one partner, and low sexual desire tends to be more common in females than males (Segraves & Segraves, 1991). Female sexual interest/arousal disorder may be treated from individualistic and systemic perspectives, and an integration of these approaches, called the intersystem approach, can be beneficial. Intersystem treatment consists of lowering response anxiety, helping the couple see the issue through a systemic lens, improving the couple’s communication regarding sexual intimacy, improving overall intimacy in the relationship, working with underlying fears, and behavioral interventions such as sensate focus (Hertlein et al., 2007). This approach takes into account the intra- and interpersonal aspects of this low sexual desire.
Female orgasmic disorder is another fairly common sexual dysfunction impacting women. According to the APA (2013a), the prevalence of female orgasmic problems varies between 10% to 42% of women, based on age, culture, duration, and severity. Laumann et al. (2009) found that about 20% of American women had experienced the inability to orgasm and that 5.7% of women frequently were unable to orgasm. The statistics from the APA and Laumann et al. are only based on the inability to orgasm and do not take into account the level of distress for those symptoms, and thereby they do not mean that all of those women would meet the criteria for female orgasmic disorder. The criteria for female orgasmic disorder requires that there are few to no orgasms or a marked reduction in orgasmic sensations, experienced in the past six months (American Psychiatric Association, 2013a). The most common form of female orgasmic difficulties are in vaginal intercourse, though some females do not experience orgasms in any partnered or solo sexual activities (Spence, 1997). There are varied mental and physical stimulations that impact female sexual arousal and orgasm, and there is not one way that women experience orgasms (American Psychiatric Association, 2013a; Carnes et al., 2005; Kope, 2007).
Both physical stimuli and the female’s response to the physiological changes in her body impact both arousal and orgasm. Kope stated that “(t)he brain is the primary site of orgasm for women” (2007; p. 97) to support her position on the importance of non-genital factors with this disorder. Whipple and Brash-McGreer (1997) discussed female sexual response with four factors: the capacity to experience pleasure, openness to sexual pleasure, physical capacity to respond to sexual stimulation, and the ability to experience orgasm. Counseling treatment for female orgasmic disorder should be undertaken after a physical evaluation by a medical doctor to rule out any physiological cause. Facilitating the exploration of past pleasurable and non-pleasurable sexual experiences, of what is sexually stimulating and pleasurable (both mentally and physically), and of how she experiences sexual arousal can be beneficial in treatment to aid in increasing awareness and pleasurable sexual arousal that could lead toward experiencing orgasm (Kope, 2007). Treating any comorbid sexual dysfunctions in the partner (including erectile disorder, male hypoactive sexual desire disorder, and female sexual interest/arousal disorder) is also important because of how the sexual problems are impacting both partners and impacting their sexual and non-sexual interactions.
The third sexual dysfunction for women is genito-pelvic pain/penetration disorder and includes two previous DSM-IV-TR diagnoses: dyspareunia and vaginismus. Because of the comorbidity of the two previous diagnoses and the difficulty in differential diagnosis, the two were combined into the current nomenclature (IsHak & Tobia, 2013). The APA (2013a) reported that about 15% of North American women experience pain during intercourse, and Laumann et al. (2009) found that 19.7% of women said that sex was not pleasurable (4.2% said it was frequently so) and that 12.7% of women said that they experienced pain during sex (2.8% said frequently so). There can be physiological and psychosocial reasons for genito-pelvic pain/penetration disorder, including anxiety and other psychological symptoms, gastrointestinal problems, provoked vestibulodynia, overactive muscles on the pelvic floor, previous trauma, relational problems, and sexual distress, and treatment is provided by different health care professionals including medical doctors, physical therapists, sex therapists, and mental health professionals (Rosenbaum, 2013). This disorder can be one of the most difficult of the sexual dysfunctions to treat with cultural messages, physical and/or mental pain, and relational conflict and/or distress as relevant factors to experiencing genital lubrication, pain, receptivity, and pleasure (Bley, 2007; Hertlein et al., 2007; Kope, 2007; Rosenbaum, 2013). Muscle relaxation, mindfulness techniques, anxiety-reduction techniques, systematic desensitization and other behavioral techniques, individual and couples therapy, physical exercise, and medications are possible treatments for genito-pelvic pain/penetration disorder (Bley, 2007; Rosenbaum, 2013).
Other Sexual Dysfunction Disorders
There are three other sexual dysfunctions that have not yet been mentioned: substance/medication-induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction. Substance/medication-induced sexual dysfunction is appropriate to diagnose when a substance (i.e., alcohol, opioids, sedatives, cocaine, etc.) or medication is causing the sexual dysfunction symptoms. This is often the case with antidepressants, antipsychotics, and hormonal contraceptive medications (American Psychiatric Association, 2013a) causing decreased blood flow or lubrication. Other specified sexual dysfunction is appropriate to use when the person does not meet the full criteria for any of the sexual dysfunctions and the clinician wants to indicate another reason for the sexual dysfunction (e.g., sexual aversion or hypersexual) or can be used for sexual dysfunctions that evolve after the DSM-5 was published. Unspecified sexual dysfunction is used when the clinician does not specify the reason for not meeting the criteria for another sexual dysfunction or can be used on a provisional basis when there is not enough information to accurately diagnose the symptoms (American Psychiatric Association, 2013a).
Paraphilias and Paraphilic Disorders
There is another category of sexual concerns that the DSM-5 has categorized as paraphilias. According to the APA (2013a), “The term paraphilia denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” (p. 685). In other words, paraphilias are atypical sexual preferences. Some people have desires for or are sexually aroused by exposing their genitals to unsuspecting others, giving or receiving pain during sexual activities, inanimate objects, or cross-dressing. Having a desire for such stimuli is not diagnosable in and of itself; the paraphilia needs to cause the individual clinically significant distress or impairment or cause harm or risk of harm to another person for an accurate diagnosis as a paraphilic disorder (American Psychiatric Association, 2013a). Richard Krueger and Meg Kaplan (2001), renowned experts in sexual therapy and paraphilias said, “Many of the paraphilias blend with consensual sexual practices that are not a source of distress or impairment of functioning but rather constitute forms of sexual expression that are chosen and practiced by significant numbers of people” (p. 391), illustrating that there are significant and important differences between paraphilias and paraphilic disorders. Some paraphilias can be healthy in sexual expression and practice for some people, and paraphilic disorders cause distress and/or impairment and can become the focus for treatment in counseling.
The DSM-5 contains eight specific paraphilic disorders, as well as two diagnoses for other specified and unspecified paraphilic disorders. Voyeuristic disorder is characterized by being aroused from watching unsuspecting person(s) disrobe, be naked, and/or engage in sexual acts. Exhibitionistic disorder is being aroused from exposing one’s genitals to unsuspecting person(s). Frotteuristic disorder is characterized by arousal from touching or rubbing against nonconsenting person(s). Sexual masochism disorder is characterized by arousal from being humiliated, beaten, bound, or other forms suffering, and sexual sadism disorder is arousal from inflicting a form of suffering on another person(s). Pedophilic disorder is sexual interest and arousal in prepubescent child(ren). Fetishistic disorder is sexual arousal from nonliving or specific nongenital body part(s), and transvestic disorder is characterized by arousal from cross-dressing (American Psychiatric Association, 2013a). Experiencing the descriptors listed is not enough to be accurately diagnosed with and treated for those paraphilic disorders, there also needs to be clinically significant distress from the thoughts, desires, or experiences and/or that there have been specific sexual behaviors acted out upon nonconsenting persons.
There are two general subcategories of paraphilic disorders in terms of diagnostic criteria for the paraphilic disorders in the DSM-5. The first subcategory contains disorders that must cause clinically significant distress or impairment (including sexual masochism, fetishistic, and transvestic disorders), and the second category can cause clinically significant distress or impairment or has been acted out with nonconsenting person(s) (including voyeuristic, exhibitionistic, frotteuristic, sexual sadism, and pedophilic disorders). All paraphilic disorders can be manifested by fantasies, urges, and/or behaviors to fit the diagnostic criteria (American Psychiatric Association, 2013a).
Treatment for paraphilic disorders is relatively similar for each disorder, although treatment can be difficult (Sandat, 2014). Treatment typically aims to achieve four outcomes: (a) reducing the frequency and intensity of sexual desires and arousal, (b) increasing awareness, (c) controlling exposure of sexually arousing stimuli, and (d) treating comorbid disorders (Kaplan & Krueger, 2012; Sandat, 2014). Cognitive-behavioral therapy (CBT), along with medication, is typically recommended by researchers and clinicians in this area, though there is limited evidence for the utility of CBT with these disorders (Garcia & Thibaut, 2011; Kaplan & Kreuger, 2012; Thibaut, 2012). CBT has been recommended because it helps people with paraphilic disorders with cognitive distortions by examining and challenging their irrational beliefs, using social and assertiveness skill training, sexual education, helping with intimacy deficiencies, and addressing any trauma history (Kaplan & Krueger, 2012). Garcia and Thibaut (2011) suggested combining CBT with sexual impulse training, relapse prevention, empathy training, and biofeedback. A combination of counseling and medication is often recommended. Gonadotrophin-releasing hormone analogues (GnRH), selective serotonin reuptake inhibitors (SSRIs), and steroidal antiandrogens have been recommended based on increasing evidence for their efficacy with paraphilic disorders (Garcia & Thibaut, 2011; Thibaut, 2012).
There are a lot of similarities to hypersexual or SCAD behaviors with behaviors of several mental health and substance disorders. There are compulsive, addictive, and dependence components to SCAD, and people tend to view this through a certain framework based on the name that they use for this. So while naming a phenomenon is sometimes a mundane activity, naming excessive sexual behaviors does seem to impact the lens through which compulsive sexual behaviors are viewed. For example, these behaviors are compulsive similar to obsessive-compulsive disorder, in that the behaviors may be done in an effort to decrease anxiety and pain (Goodman, 2001). With this perspective, treatment would focus on
decreasing and controlling compulsive sexual behaviors and urges by increasing self-management and self-control.
Unlike compulsions, sexual behaviors often are pleasurable and enjoyable, which is more like an addiction as SCAD behaviors are driven, enjoyable, and reduce a strong impulse to partake in those behaviors (Goodman, 2001). Treatment implications from an addictions framework may lead to focusing on people ceasing all relevant behaviors (sobriety) and learning to support oneself with internal and external resources are goals within this perspective. However, there are problems applying the sobriety approach with sexual activities. Would the goal of treatment really be to cease all sexual activities? Although complete cessation of certain behaviors (i.e., any that are harmful to oneself or others) may be appropriate, it may not be possible or desirable for people to aim to cease any and all sexuality-related involvement and activities, given that sexuality is a central aspect of people’s lives. Therefore, addiction-focused treatment may require modifications from typical interventions used in relations to substances when applied to compulsive sexuality-related behaviors.
Hypersexuality is a term that has been proposed by some that emphasize that “excessive” sexual activity is culturally and contextually based and that there are more problems in conceptualization and treatment when using other nomenclature. This perspective focuses more on the symptoms that a person experiences and how that is negatively impacting functioning (Kafka, 2010; Kaplan & Krueger, 2010). These are legitimate and important viewpoints to critically examine and reflect upon if planning to work with this population because of the pros and cons to each of the perspectives. For the sake of convenience, the name “hypersexuality/SCAD” will be used in the rest of this chapter to emphasize the different perspectives that can be used with this phenomenon.
Hypersexuality/SCAD can cause significant problems in functioning and relationships. People who excessively engage in sexual activities may face negative impacts in other areas of functioning (vocational, economic, social, familial, etc.) and cause significant distress (Giugliano, 2008; Goodman, 2001; Kafka, 2010; Kafka & Hennen, 1999; Kaplan & Krueger, 2010). People with hypersexuality/SCAD often engage in sexual activities without intimacy and connection to the person(s) that they are sexually active with, in risky settings, and despite recurrent negative effects in their lives. The activities that people with hypersexuality/SCAD engage in can vary from compulsive masturbation, pornography use, telephone and/or cyber sex, promiscuity, and strip club usage (Kafka, 2010; Kaplan & Kreuger, 2010), and many have other addictive behaviors with substances, work, eating, and/or spending (Carnes et al., 2005).
As mentioned before, there is a significant connection between sexuality and substance abuse, and there is also a significant connection between hypersexuality/SCAD and other addictions. In a study of 1604 participants, Carnes et al. (2005) found that 80% of gay males, 79% of heterosexual females, and 69% of heterosexual males with hypersexuality/SCAD also met criteria for an addictive disorder. They also found that over 40% simultaneously engaged in sexual behaviors in conjunction with the substance to which they were addicted, as well as that over 50% had other family members who also were addicted to something. In reviewing the mental health literature comorbidity with hypersexuality/SCAD, Kafka (2010) reported that people with hypersexuality/SCAD are more likely to have sexual dysfunctions and eating, mood, anxiety, substance abuse, and impulse control disorders. Black, Kehrberg, Flummerfelt, and Schlosser (1997) found that 86% of a sample of 36 participants with compulsive sexual behavior also had an axis I DSM-III-R diagnosis.
Treatment for hypersexuality/SCAD often includes impulse control training, emotional-regulation skills training, some form of abstinence, referral to the 12-step Sexaholics Anonymous program, relapse prevention, examining and otherwise fulfilling underlying needs and desires, couples therapy, treatment for comorbid diagnoses, and medication (Carnes, 2000; Carnes et al., 2005; Goodman, 2001; Kaplan & Kreuger, 2010; Sugrue, 2007). There are many theoretical approaches used to work with people with hypersexuality/SCAD, and treatment is typically an integrated approach to holistically cover all of the presenting concerns and is expected to last longer than treatment for most other presenting concerns (Carnes, 2000; Sugrue, 2007).
Sexual Variations and Atypical Behaviors Sexuality can be expressed and enjoyed in many different ways. While this chapter has covered many sexual difficulties and some things that are atypical sexual desires or concerns, sexual desires and behaviors do vary among people who are sexually health. There is no one way that healthy sexuality is expressed, as healthy sexual expression covers a broad range of activities and really is dependent on the consent, impact on functioning, and sexual, romantic, and overall satisfaction. Therefore, it is important for counselors to consider their beliefs about what is “normal” sexual behavior and to avoid imposing their sexual values on clients. Exercise 6.1 will help you to think about your sexual values and beliefs.
Exercise 6.1
Guided Reflection About Healthy Sexual Behaviors
The following list of sexual activities can help you consider your thoughts on healthy sexuality. For each activity on the list, think about in what circumstances and how frequent it is healthy to engage in the following sexual activities. In terms of circumstances or frequency, you may think that it is not healthy to engage in the particular activity, and you can indicate that in your response.
Sexual Activity Circumstances (partnered, alone, group, etc.)
Frequency•Kissing•Hugging•Petting•Hand or Manual Sex•Oral Sex•Genital Sex•Anal Sex•Group Sex•Swinging Sex (trading partners)
Sexual Trauma Sexual trauma also significantly impacts how an individual experiences and acts as a sexual being. Sexual trauma, including rape, childhood sexual abuse, and unwanted sexual experiences, can happen at any age and can have significant physiological, mental, and interpersonal repercussions (Planty, Langton, Krebs, Berzofsky, & Smiley-McDonald, 2013). Therefore, counselors need to be aware of the impact of sexual trauma and of recommended treatment approaches to help clients to heal. Incidents of sexual trauma are unfortunately relatively commonplace. The impact of sexual trauma can last for years, although with treatment, many survivors are able to enjoy sexual relationships and activities (Woodward & Joseph, 2003).
Sexual trauma is an umbrella term that includes rape, incest, childhood sexual abuse, molestation, sexual harassment, and unwanted sexual experiences. Sexual trauma unfortunately is a common issue today. Many researchers (e.g., Putnam, 2003) have reported on the problems that can stem from experiences with sexual trauma. However, recently, some researchers (Calhoun & Tedeschi, 2004) have also focused on the resilience and possible growth that people can have through healing from sexual trauma and from other life changes that bring about further growth. Therefore, it is important to avoid pathologizing people who have experienced sexual trauma, and counselors can help these clients identify both the challenges and strengths they have encountered as a result of the trauma they faced. In this section, the types of sexual trauma will be discussed, and then treatment considerations will be provided.
Childhood Sexual Abuse Childhood sexual abuse (CSA) is also a broad term that covers many types of different sexual trauma. Incest (i.e., sexual activity between family members that are too closely related to marry), rape (i.e., vaginal or anal penetration by any body part or object or oral penetration by a sexual organ), childhood pornography (i.e., pornographic material of people under the age of 18), and unwanted sexual experiences (i.e., any sexual activity that was not desired) are all specific examples of CSA. To be categorized as CSA, most experts agree that sexual contact (a) needs to be between a child and someone five or more years older than the child or (b) needs to be done without the child’s consent (Browne & Finkelhor, 1986; King & Regan, 2014). There may or may not be violence, forced activity, or consent given to classify as CSA. Most perpetrators of CSA are known by the child and are male (Berliner & Elliott, 1996; Finkelhor, 1991; Morison & Greene, 1992). While many think of child molesters as “dirty old men,” this stereotype is not accurate (Fuselier, Durham, & Wurtele, 2002; Laumann et al., 1994).
There have been various findings for the prevalence of CSA, though in several studies, researchers have consistently reported that between 10% to 20% of children under the age of 18 experience some form of CSA by the time that they are 18 years old (Pereda, Guilera, Forns, & Gómez-Benito, 2009). The statistics differ for females and males, with females (25.3% of population) being more likely than males (7.5% of population) to experience and report CSA (Pereda et al., 2009). Researchers typically find that females are 2.5 to 3 times more likely to experience CSA than males (Putnam, 2003). Some researchers have suggested that CSA for males may actually occur at higher rates that may even approach the rates for females, but social stigmatization and conditioning may lead males to not report CSA or to not see that they have experienced CSA (Finkelhor, 2010; Pereda et al., 2009). Males are commonly seen as sexual aggressors, and even if the child is a male and the adult is a female, people often assume that it was not abusive because they think the male may have enjoyed the experience or even may have initiated the sexual activity (Finkelhor, 2010). Age is another important factor with CSA. About a quarter (26.3%) of CSA cases in the United States were made against 12- to 14-year-olds (United States Department of Health and Human Services, 2013). Almost two-thirds of people who experienced CSA were between the ages of 9 and 17, with the age ranges of 15- to 17-year-olds (20.9%) and 9- to 11-year-olds (18.4%) both having about a fifth of the substantiated CSA cases. Children under the age of 9 are also at risk of CSA, with prevalence rates of 2.6% for 0- to 2-year-olds, 14% for 3- to 5-year-olds, and 17.2% for 6- to 8-year-olds (United States Department of Health and Human Services, 2013). Overall,
children between the ages of 12 and 17 are at greater risk in the United States, and children between 6 and 11 years old also face a significant risk.
The consequences of CSA are difficult to clearly measure and identify. While negative mental health, physiological, and social effects are correlated with CSA, attributing the results solely to CSA is difficult because negative familial and socioeconomic factors are commonly experienced alongside CSA (Putnam, 2003). Absent parents, the presence of stepparents, parent mental illness and/or substance use problems, and social isolation are common in the families of children who experience CSA, and each of these factors also negatively impacts mental health (Putnam, 2003). However, CSA has the potential to negatively impact people’s sexual development, especially if they do not heal through treatment or other efforts. Some of the specific long-term impacts may include negative beliefs about sex and relationships, unclear boundaries, unbalanced hierarchical power structures, and difficulty identifying sexual coercion. Each of these issues may impact clients’ needs in counseling.
Rape Rape is another common form of sexual abuse, with approximately one-fifth of women experiencing rape or attempted rape at some point during their lifetimes (Black et al., 2010). Over 10% of high school females have had sex when they did not want to (Kann et al., 2014). Planty, Langton, Krebs, Berzofsky, and Smiley-McDonald (2013) found that around 270,000 females experienced rape or sexual assault in 2010. Typically, rape is perpetrated by one male against one female without a weapon (in about 90% of cases) (Planty et al., 2013). However, rape can happen to males and can be perpetrated by females. Rape also is typically perpetrated by someone known to the person who experienced rape, which is the case in about 78% of cases (Planty et al., 2013). Rape, as defined above, is the vaginal or anal penetration of any body part or object or oral penetration of a sexual organ (Federal Bureau of Investigation, 2013) and can cause substantial mental and physiological harm. Between 2005 and 2010, approximately 60% of women who were raped were injured during the assault, although only 35% of those injured women sought treatment for the injuries (Planty et al., 2013). Mental injuries also can occur, impacting mood, self-esteem, anxiety, substance abuse, and suicidal thoughts (Campbell, 2008). If untreated, symptoms could develop to the point of meeting the criteria for mental health disorders such as post-traumatic stress disorder and major depressive disorder. Communities often have physical, legal, and mental health services for people who have experienced rape, and 77% of people who were raped received assistance from a victim service agency (Planty et al., 2013).
Sexual Harassment Sexual harassment, as defined by the United States Equal Employment Opportunity Commission (EEOC), is “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” (n.d.). To qualify as sexual harassment, the verbal or non-verbal behaviors need to be unwanted and of a sexual nature. In 2011, there were almost 34,000 resolved cases of harassment with 20% receiving merit resolutions totaling over $100 million in monetary benefits by the EEOC, which does not count any civil lawsuits (EEOC, n.d.). While there were over 30,000 reported cases, there are many more unreported cases of sexual harassment. Das (2009) found that 41% of women and 32% of men have experienced sexual harassment at work. This can lead to negative changes, and Chan, Lam, Chow, and Cheung (2008) found that experiencing sexual harassment is related to decreased job satisfaction, commitment, and performance, physical health, and psychological wellbeing.
Treatment of Sexual Trauma Negative short- and long-term problems can arise from sexual abuse (Chan et al., 2008; Pereda et al., 2009). The negative personal and social changes are important to take into account, and the decreases in the person’s ability to function in vocational, social, and familial areas are also important to address. This is especially true for CSA, and some see CSA as one of the most serious public health problems (Pereda et al., 2009). In one study, 62.8% of children that had been sexually abused met diagnostic criteria for at least one mental health diagnosis, and 29.5% met criteria for two or more diagnoses (McLeer et al., 1998).
There are several treatment models for treating trauma and even more models for treating mental health symptoms (e.g., depression, anxiety, self-esteem, and stress) associated with sexual trauma. Trauma-focused cognitive behavioral treatment (TF-CBT), the triphasic model, eye movement desensitization and reprocessing (EMDR), self-trauma model, and medication are all approaches that have demonstrated some efficacy of treating sexual trauma. When treating sexual trauma, it is important for counselors to consider the sexual and non-sexual symptoms of the client along with the characteristics of your client, your own theoretical orientation and client conceptualization, and the research showing the efficacy of different approaches to best select the best treatment for your client. It is also important to consider and discuss with your client the focus of treatment (which may or may not include treatment of past sexual trauma) and how much emphasis to put on working with the client on sexual trauma before assuming her or his intentions and desires and trying to put more or less focus than the client is expecting. Counselors also should remember the importance of recognizing the potential for post-traumatic growth to occur via healing after the trauma. Calhoun and Tedeschi (2004) found that nearly half of people who have experienced a traumatic event report some benefit later in life. Counselors can best support their clients in navigating the challenges associated with sexual trauma by focusing on clients’ strengths and resources and by providing a non-stigmatizing, supportive context for healing to occur.
Summary In conclusion, there is a complex relationship between people’s mental health and their experiences of sexuality. Counselors working with clients to address sexuality-related concerns must consider the various ways that these two dynamics intersect. From a cognitive standpoint, there are a number of possible influences on the processes that clients use to make decisions related to their sexuality, even allowing room for some of these decisions to be made spontaneously and without much forethought or planning. Other intersections between sexuality and mental health can be found in the links between sexuality and mental health disorders, substance abuse, and specific sexual dysfunctions. Furthermore, clients who have experienced sexual trauma may find that there are long-term impacts of the trauma—both positive and negative—that impact their sexual functioning and attitudes. Overall, these various influences offer counselors a wide range of opportunities to address clients’ experiences with sexuality and link those experiences with their mental health functioning.
Keystones •Sexuality and mental health have a dynamic and bidirectional relationship, in which changes in one area directly impact the other.•Many factors impact people’s decisions whether, when, and how to engage in sexual activities.•Many common mental health and substance abuse disorders—including anxiety and mood disorders—have implications for clients’ sexual functioning.•Counselors should familiarize themselves with the sexual dysfunctions outlined in the DSM-5.•Sexual trauma can have significant short- and long-term impacts—both positive and negative—on clients’ sexual attitudes, experiences, and functioning.
Additional Resources
•International Institute for Trauma and Addiction Professionals. (2015). Sex Addiction Therapist Training. Retrieved from http://www.iitap.com/events/sex-addiction-workshops•Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. New York, NY: Bantam Books.•Schnarch, D. (1998). Passionate marriage: Keeping love and intimacy alive in committed relationships. New York, NY: Owl Books.•VandeCreek, L., Peterson, F. L., & Bley, J. W. (2007). Innovations in clinical practice: Focus on sexual health. Sarasota, FL: Professional Resource Press.
