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This document contains chapters 16 to 17 Chapter 16 Sexually Transmitted DiSeases, HIV/AIDS, and Sexual decisions TOTAL TEACHING PACKAGE OUTLINE Lecture Outline Resources Reference Chapter 16: Sexually Transmitted Diseases, HIV/AIDS, and Sexual Decisions AN OVERVIEW OF THE HIDDEN EPIDEMIC Teaching Suggestions: 1(A), 2(A-D). 3(A), 3(B), 4(A), 6(A), 8(A) Learning Objectives: #1,2,3,4,5,6,7,8,9,10,11,12 NONVIRAL SEXUALLY TRANSMITTED diseases Teaching Suggestions: 1(A), 2(A-D), (A), 3(B), 4(A), 6(A), 8(C) Learning Objectives: #13,14,15,16,17,18,19 VIRAL SEXUALLY TRANSMITTED diseases Teaching Suggestions: 1(A), 2(A-D), 3(A), 3(B), 4(A), 6(A), 8(B) Learning Objectives: #20,21,22 OTHER SEXUALLY TRANSMITTED diseases Teaching Suggestions: 1(A), 2(A1-4), 3(A), 3(B), 4(A), 6(A) Learning Objectives: #23,24 HIV: THE VIRUS AND THE INFECTION Teaching Suggestions: 1(B-C), 2(F-H), 4(A), 5(A-B), 8(D) Learning Objectives: #25,26,27,28,29 HIV TESTING, TREATMENT, AND VACCINES Teaching Suggestions: 1(B-C), 2(F-H), 4(A), 5(A-B), 8(E) Learning Objectives: #30,31,32,33,34,35,36,37, 38,39 CAN SEX BE SAFE AND SATISFYING? Teaching Suggestions: 5(A), 6(A), 7(A), 7(B) Learning Objectives: #40,41 LEARNING OBJECTIVES After reading this chapter, students should be able to: Describe historical and cultural perceptions of STDs. Describe development in the treatment of STDs. Describe difficulties associated with reporting the incidence of STDs. Briefly describe reasons why individuals do not seek treatment for STDs. Describe the historical roots of Human Immunodeficiency Virus (HIV) and aspects of HIV which remain unknown. Briefly describe the epidemiology of HIV. List and describe three nonsexual means of transmitting HIV. List estimates and trends of world rates of HIV infection List and describe five geographical areas with high rates of HIV infection. List and describe the epidemiology, symptoms, diagnosis, and treatment of gonorrhea. List and describe the epidemiology, symptoms, diagnosis, and treatment of syphilis. List and describe the epidemiology, symptoms, diagnosis, and treatment of chlamydia. Describe the causes, symptoms, and treatments for nonspecific urethritis (NSU). Briefly describe vulvovaginitis and its symptoms. List and describe four types of vulvovaginitis (bacterial vaginosis, yeast infection, trichomoniasis, atrophic vaginitis). Briefly describe methods to prevent vulvovaginal infection. Describe the epidemiology, symptoms, diagnosis, and treatment of genital herpes. Describe the epidemiology, symptoms, and treatment of genital warts (HPV). Describe the epidemiology, symptoms, and treatment for hepatitis B (HBV) and hepatitis C (HCV). Describe the epidemiology, symptoms, and treatment for pubic lice. List and briefly describe two sexually transmitted skin infections. List and briefly describe three sexually transmitted diseases (STDs) associated with tropical climates. List and describe the stages of HIV infection/disease. Briefly describe the RNA/DNA relationship of HIV. Briefly describe the immune system responses to HIV infection. List the typical fluids and routes involved with the transmission of HIV. Describe the risks of HIV infection associated with oral sex, kissing, and casual contact. List and describe two HIV blood tests, and one HIV antigen test. List three outcomes of HIV testing. Describe social and legal controversies over HIV testing. List six Centers for Disease Control (CDC) recommendations for HIV testing. Identify the latest strategy regarding microbicides and HIV prevention. Describe treatments for HIV infection. Describe three complications with developing a vaccine for HIV. List and describe suggestions for minimizing the risks of getting and transmitting an STD. Describe some of the controversies over HIV/AIDS education. List and describe ten suggestions for minimizing chances of contracting or transmitting an STD or HIV. CHAPTER OVERVIEW This chapter offers a straightforward discussion of sexually transmitted diseases (STDs) and a variety of other medical conditions that can affect the sex organs and sexual activity. Whereas STDs once were discussed only briefly in most human sexuality courses, they are emerging as important issues again. Considering that the incidence of several diseases is on the rise, and that more organisms are being recognized as being capable of sexual transmission, such a trend may be timely. One of the most significant findings of the National Health and Social Life Survey (NHSLS) was the direct correlation between the numbers of sexual partners people have had and the likelihood that they will have had aSTD . The positive correlation between the two factors is clearly indicated in the tables in this chapter and the text discussion. STDs have caused much human misery throughout the centuries and continue to represent serious health problems today. The development of penicillin was a major step in conquering some STDs. It is estimated that there are 18.9 million new cases of STD in the United States each year, 48% (or 911 million) of those cases occurring in people aged 15 - 24. Fifty-six million people (1 in 5) in the United States are infected with some form of viral STD. Many people have convinced themselves that they are not susceptible to STD; this continues to reinforce the negative social stigma that contracting an STD can bring. The more sexual partners an individual has, and people who have negative emotions about having sex in the first place are less likely to use or consistently use condoms, the more likely infection with an STD becomes. (The sentence not clear; not sure how to clarify…) Human immunodeficiency virus (HIV) has created many medical, political, economic, and social issues. Acquired immunodeficiency syndrome (AIDS) was first identified in 1981. It is a disease that progressively destroys the body’s immune system, so that opportunistic infections weaken the victim. It is eventually fatal. Although the origins of HIV are uncertain, it may have begun in Africa. HIV disease has infected millions of people throughout the world and is considered a pandemic. Epidemiological studies show that the incidence of HIV infection varies in different parts of the world. Although HIV spread first among gay males and intravenous drug abusers in the U. S., HIV infection is now present among heterosexual adolescents, women, and children. In sub-Saharan Africa and South and Southeast Asia, the rates of HIV infection and AIDS are particularly high. Gonorrhea can be spread through vaginal, anal, and oral sexual contact and infects more than a half million people each year. The eyes of babies are vulnerable to infection during birth and are routinely treated to prevent gonorrheal blindness. Many strains of gonorrhea are now penicillin-resistant, so other antibiotics are used for treatment. Syphilis progresses through four major stages. About 20,000 people each year in the U.S. are infected with syphilis. Syphilis is curable until the tertiary stage. The large proportion of the population infected with the chlamydia organism was not recognized until the mid-1980s. It is the cause of many different forms of genital and urinary tract infections in both men and women and can cause infertility. It is one of the most common STDs of all reportable communicable disease. Nonspecific urethritis (NSU) has been steadily increasing as an STD problem in males. Vulvovaginal inflammation may be caused by bacteria, yeast organisms, or trichomonads. Taking proper hygienic measures and keeping the vulval area dry can reduce the risk of contracting vaginitis. Genital herpes is caused by the herpes simplex virus. Once the virus has infected the body, it can cause recurrent outbreaks of lesions. The disease has been associated with a higher incidence of cervical and vulval cancer in women and can be dangerous to newborn infants. Genital warts (condylomata acuminata) are caused by the human papillomavirus (HPV) and are associated with a higher incidence of cervical and anal cancers. Hepatitis B virus (HBV) can cause serious liver infection, and it has now been recommended that college students be vaccinated against the virus. Hepatitis C virus (HCV) is also a serious disease, but it is less likely to be transmitted sexually. Hepatitis A (HAV), which is primarily transmitted through fecal matter, is now considered an STI due to oral-anal contact. Pubic lice must be thoroughly treated to ensure that all insects and their eggs have been eliminated from bodily hairs. Lymphogranuloma venereum, chancroid, and granuloma inguinale are sexually transmitted diseases that are more common in tropical climates. Two skin diseases that may be transmitted by the intimate bodily contact of sex are mulluscum contagiosum and scabies. HIV is transmitted from mother to infant, but not all infected children develop disease symptoms, and preventive treatments can reduce the risk. HIV is more prevalent in poverty stricken urban neighborhoods, especially where a great deal of IV drug abuse occurs. This could represent a challenge to maintaining funding for seeking a cure for the disease. HIV is a retrovirus, and several strains have been identified. The virus can probably attack several human tissues, but it particularly affects the T-lymphocytes known as CD4 cells that are crucial to the immune system. The documented routes of HIV infection are anal or vaginal intercourse; oral-genital sexual activity; other contacts with semen, vaginal fluid, transplanted organs, or blood (as through contaminated needles); and transfer from mother to child perinatally or through breast milk. Tests that detect HIV antibodies in the blood may not show evidence of the virus for months, although symptoms develop about 6 weeks after initial infection. The ELISA test is usually confirmed with the Western blot test. Many states now require premarital testing and testing for those seeking immigrant visas and people enlisting in the military. Home testing raises the problem of being notified of results without assurances of face-to-face counseling. There is no cure for HIV infection. Treatment focuses on prevention and control of opportunistic infections. Research is focusing on the development of a vaccine to produce immunity to the virus, thus preventing infection. Part of responsible sexual decision making is to take appropriate measures to prevent the transmission of STDs. Considering abstinence, avoiding penetration, avoiding multiple partners, taking personal responsibility for yourself and for your protection (avoiding abuse of alcohol or other drugs that impair judgment, knowing partners, etc.), getting screened from disease, and using condoms, vaginal pouches, and spermicides are among the best preventive precautions. If infected, prompt medical treatment is essential, as is telling any potentially infected partners. Many drugs have been developed to treat HIV, and combination drug therapies involving protease inhibitors are proving to be the most effective. HIV can develop drug resistance because it mutates quickly and multiplies in great numbers. Many other drugs are being developed and tested. Vaccines to fool the body into creating antibodies to help slow the rates of HIV infection are being tested. Preventive vaccines are also being tested. TEACHING SUGGESTIONS 1. Discussion Topics A) Discuss the legal issues regarding having an STD and not telling partners. Encourage students to consider the social implications of: — A 15-year-old female who is diagnosed with herpes. — The stigma that STDs can elicit as compared to someone diagnosed with cervical cancer or diabetes or alcoholism or erectile dysfunction. — A member of congress introducing mandatory HPV screening (pap smears) for women who receive state and/or federal assistance, women prior to granting a marriage license or divorce, and women in jail or prison. Ask the class if they are aware of any people who have been sued because they failed to reveal that they had a contagious STD. If you have examples, share them. Then read “A Lover's Legal Checklist” (in the main text). Facilitate a discussion on whether or not the class thinks such a guideline is good or does it diminish the romance? Would they use it? Why or why not? How would they change it? B) Introduce the information regarding the statistics on the prevalence of HIV and AIDS infection. After reviewing the statistics, ask if anyone has not heard of the epidemic before. Find out when they began to first hear about HIV/AIDS. Who told them about it and what did they say? Ask if anyone is unsure of the best ways to prevent contracting HIV/AIDS (e.g., abstinence, use a condom, be in a trusting, committed relationship). Now ask how many of them know of someone who still practices unsafe sex. Probably several people will raise their hands. Even if no one raises their hand, ask why some people still don’t practice safe sex, even with all of the education. This will be a lively discussion. C) Discuss the ways that HIV is transmitted. Then ask students to talk about how an infected person should be treated, remembering that many are asymptomatic for years and lead normal lives. Then ask if they would want someone who is HIV positive as a roommate or as a coworker. Would they let an HIV-positive friend babysit their child? Would they have sex with someone who is HIV positive? What if their husband or wife had become infected through a blood transfusion? 2. Role-Plays Have students role-play the following scenarios: Asking a partner about past sexual experiences. Wanting to use a condom when your partner doesn’t. Discussing getting tested for STDs with a new partner before you become intimate. Telling someone you really like and want to be with that you have an STD. This is done in two parts: the first part is someone with a bacterial STD and the second is someone with a viral STD. After five years, an ex-boyfriend or girlfriend contacts you and tells you he or she is HIV positive. You and the person are talking. You are the parents of a three-year-old who is HIV positive; you are told that your child cannot continue in preschool. You and your roommates go together to be tested and one is negative and the other is positive. An insurance company cancels a policy because you are HIV positive, leaving you without insurance. 3. Case Study Questions A) The case study of “Carolyn Discovers a Sexually Transmitted Infection” (in the main text) provides a good foundation for discussing honesty within a relationship. Remind the class that most people want to make a good impression and are reluctant to share things that they feel the other person might not approve of, such as a one-night stand that happened before Carolyn and her boyfriend met. Areas to explore with the class: How do you know someone is really telling you the truth about previous partners? Do you know people who have omitted certain information about their past? Have you? At what point in a relationship do you have unprotected sex? Do you think Carolyn’s relationship can survive? When do you talk about getting tested for STDs? The emphasis is on getting tested for HIV, not other STDs. B) “Cross-Cultural Perspective—The Other Epidemic” (in the main text) shows how women in other countries, who have no power over their sexuality, are faced with contracting STDs from their husbands at an alarming rate. Ask students for their reaction to this case study. What do they think contributes to this situation and what could be done, if anything, to change it? Where does the change need to come from? Have they known anybody who was rejected because they had an STD? 4. Essays/Papers A) Ask students to respond to one or more of the following questions that are also found in the chapter: How comfortable do you feel asking a potential partner about her or his history of STDs? Describe what you would say and how in-depth you would go. How would you inform a partner of your history? Is there an area you would feel uncomfortable sharing? Discuss what criteria you use to determine if you believe someone or not. Should there be mandatory HIV testing? If the results are positive, should individuals be made to inform all present and past partners? Why or why not? If someone under the age of 18 wants to be tested for HIV, should they need to have parental permission? Explain why or why not. How should people with HIV/AIDS be treated? Should they be able to hold any job or live anywhere? Do they have a right to confidentiality regarding their status? Explain your answers. What are some of the problems with developing a vaccine to control HIV? 5. Large Group Activity A) As a whole, have the class discuss what the elements of a good HIV education program would be. List these on the board. The list should include things like statistics, symptoms, causes, treatments, maybe personal statements, etc. Then ask students to name particular populations that they believe could benefit from better HIV education. This list could include junior high, high school, and college students; people who are divorced or their spouses have died and they are entering the dating scene again; IV drug users; the deaf community (see the boxed feature “Silence Equals Death”), etc. This list could be long. After completing the list, ask students to break up into groups of four or five, depending on the size of your class. Next ask each group to pick a particular population. Tell them that the project is to design an effective HIV/AIDS lesson plan for that population. It is up to them to figure out what the unique challenges might be in reaching their population. Suggest that they use games, videos, demonstrations, handouts, overheads, etc. The lesson plan can be written or maybe demonstrated in front of the class. This exercise will help them think about effective ways of educating difficult-to-reach populations with a very important message. HIV Letter Objective: To encourage students to visualize the impact that choices about sexual activity now may affect their future. Method: Prior to class, handwrite the following (see the end of this activity) on a sheet of paper, photocopy so that all students have their own and fold it so that it will fit into an envelope. Distribute the folded letters to the students with instructions to not touch the document. They must leave it set until you tell them to read it. Encourage students to relax. Ask students to figure out how old they will be in 3 years. While focused on that age, ask students to imagine the answers to the questions that you will be asking. They are to ponder the answers in their mind, without discussing or verbally reacting. Because no one can know their future, they, of course, do not know the answers; however, they are individuals with goals and plans (or else they wouldn’t be in college) so they can imagine the best response. Proceed to ask the following, and then offer a multitude of possible responses to trigger visualization and stimulate creative thinking – be inclusive of cultural, ethnic, religious, socioeconomic, and orientation variances when you make suggestions: — Where will you live in 3 years? (In this state? Another state? Another continent?) — What kind of place will you live in? (A house? Condo? Barracks? Residence hall? Island hut?) — How will you earn money? — What is your primary mode of transport? — How do you spend your free time? — Are you single? Dating someone special? In a committed relationship? — Do you have a child? Children? A baby on the way? Tell students that the questions are finished and they are to listen to this story – make the story as detailed with as many adjectives as possible to encourage visualization: You come home from work or school; you pull your truck into the condo driveway, or walk from the subway stop on the corner to your apartment. Grabbing the mail from the mailbox, you then unlock your door and enter your home. You are soooo glad to be home as it has been a long and tiring day. As you walk into your place, a big dog comes up and wants your attention, “Hello puppy! Glad to see you,” you say as you then make your way to the kitchen. Throwing your keys on the counter top, you walk to the refrigerator and grab your favorite beverage – what color are your kitchen walls? As you begin your trek to the television room to sit peacefully in your favorite chair – what does your favorite chair look like? – a toddler runs up to you and grabs your leg in a giant welcome home hug! “Hi sweetie…glad to see you!” and you smile and gently disentangle yourself to again move forward to your chair. You are so fatigued…it’s really about relaxing and so you send the toddler to find a book to read. As you set your beverage on the end table and start to sit, a very special someone comes in and gives you a peck on the cheek. “Hey babe! Glad to see you! I’m so tired…I need just a minute to relax and open the mail, then I’d like to hear about your day.” Your special someone is understanding and proceeds to leave the room…looking forward to your attention in a few minutes. Ahhhh…peace. You look at the mail in your hand and start to sort through it…bill, bill, bill…so many bills. Hmmm, an interesting piece with your name and address on the envelope, but no return address. That’s the one to open first! (Prompt students to pick up the letter and begin to read with you quietly as you read out loud. After you are done reading, immediately tell students to freeze…no moving, no talking!) Ask “What are you FEELING right now?” and have students respond. Ask “What are you THINKING right now?” and have students respond. Ask “What are you going to DO about this letter?” and have students respond End this exercise by reviewing the following teaching points: You can’t change the past, so stop fretting about yesterday. You can determine your future by actions you take now. What can you do to ensure that you will not get a letter like this in the mail? When you walk through that door(s) at the end of this class, you now have no excuses - you are educated, you are informed. Make the healthiest choices possible to take care of you. Handwrite the following: Dear , I know it’s been a long time since I’ve written to you and even longer since last summer when we were going out together. There’s no easy way to tell you this so I’ll just say it. I’ve just been told by my doctor that I have HIV, the virus that causes AIDS. The doctor said that I might have been infected with it when we were going together. I don’t know what to say to you except that I’m sorry if I put you in danger of getting AIDS. Maybe you need to talk to someone who knows about the disease. I hope everything is ok for you. I’m sorry, Chris *Adapted from Steve Brown and Bill Taverner, Streetwise to Sexwise, Center for Family Life Education: Planned Parenthood Greater Northern NJ Inc., 2001 6. Small Group Activity A) Objective: To have students learn common symptoms, tests, and treatments for STDs. Method: Divide students into the number of STDs you want to cover. For instance, you might not want to deal with lice, scabies, or some of the STDs found in tropical climates. Give each group a piece of paper with an STD on it and ask them to create a list of symptoms starting with the least obvious. Have them also include tests and treatments for their STD. These lists will be used for a class quiz on STD knowledge. When each group is done, have one group begin by describing one or two symptoms. Then ask the other groups to guess what infection is being talked about. The group that can answer gets a point. Bonus points can be given if they can also tell how to test for the infection and effective treatment. After all groups have gone, add up points, and the group with most points wins. Give prizes to the winning group. Upon completion: Students will have a greater knowledge of STDs, symptoms, tests, and treatments. Guest Speakers A) Invite someone from public health or perhaps someone from the campus student health services to speak on STDs. B) Another possibility is to check for local support groups designed specifically for people with STDs and ask if they have a speaker’s bureau. Often, people are willing to come and speak to classes about living with an STD. 8. SexSource Video Bank The SexSource video bank provides an excellent array of short videos that may serve as discussion starters. In order to elicit the best responses, it is advisable to pair students in groups of two for “pair sharing.” Give them the initial starter questions below, and then show the videos after some initial discussion. Instructors should preview videos for time and content. Additionally, you may want to download clips prior to class to ensure they are ready for viewing regardless of network connectivity. All video clips may be found at: http://www.mhhe.com/sexsource STD’s: The Silent Epidemic video clip – Ask paired students: What is the best way to spread sex education? How widespread are STIs? This video shows a team that has adults working in partnership with teens, describing STIs, how they are transmitted, and how to prevent their spread. HPV video clip – Ask paired students: What is HPV? How can it be treated? How does it impact women’s lives? In this video, Jen is a mother and career woman who has been diagnosed with HPV. She was very surprised to discover she had HPV, and both she and her doctor describe how the infection affects her and women like her. Herpes video clip – Ask paired students: What is genital herpes? How is it spread? Would you know if your partner has herpes? In this video you meet Mark, who has had herpes for 23 years. Mark has learned to live with his STI, keeping track of outbreaks over the years, and participating in new research studies and drug treatments. As he is interviewed about the progress of his infection, he describes how drug management has reduced his outbreaks but will never get rid of the disease. Just Like Me video clip – Ask paired students: Have you had unprotected sex? What is the likelihood of contracting HIV from a one night stand? In this video, several HIV+ people discuss how they felt about safer sex before they were infected, and how they feel about it now. The men and women in the clip offer strategies for how to insist on safer sex, how important it is, and how they never would have thought AIDS could happen to them. Undetectable: The New Face of AIDS video clip – Ask paired students: What are the current treatment options for those infected with HIV? What are the symptoms of HIV medications? In this video, Belynda Dunn, a prominent AIDS activist, went on a new antiretroviral AIDS treatment, and went from asymptomatic to extremely ill. The new, aggressive AIDS regimens are so effective that they can reduce an AIDS patient's viral load to undetectable, but there are drawbacks and side effects to these new drug cocktails. Could you live with a treatment that kept you alive but also made your life painful and difficult? Ms. Dunn eventually made the decision to go off her medication, and has died in the time since the video was made. GLOSSARY acquired immunodeficiency syndrome (AIDS): fatal disease caused by a virus that is transmitted through the exchange of bodily fluids, primarily in sexual activity and intravenous drug use. chancroid (SHANG-kroid): an STD caused by the bacterium hemophilus ducreyi and characterized by sores on the genitals, which, if left untreated, could result in pain and rupture of the sores. chlamydia (kluh-MID-ee-uh): now known to be a common STD, this organism is a major cause of urethritis in males; in females, it often presents no symptoms. ELISA: the primary test used to determine the presence of HIV in humans. epidemiology (ep-i-dee-mee-OL-uh-jee ): the branch of medical science that deals with the incidence, distribution, and control of disease in a population. genital herpes (HUR-peez): a viral STD characterized by painful sores on the sex organs. genital warts: small lesions on genital skin caused by papillomavirus; this STD increases later risks of certain malignancies. gonorrhea (gon-uh-REE-uh): bacterial STD causing urethral pain and discharge in males; often no initial symptoms in females. granuloma inguinale (gran-yuh-LOH-muh in-gwuh-NAL-ee or –H-ley): an STD characterized by ulcerations and granulations beginning in the groin and spreading to the buttocks and genitals. hemophiliac (hee-muh-FIL-ee-ak): someone with the hereditary blood defect hemophilia, primarily affecting males and characterized by difficulty in clotting. (hemophilia was not discussed in this chapter.) hepatitis B virus (HBV): liver infection that is frequently sexually transmitted. hepatitis C virus (HCV): liver infection that may occasionally be sexually transmitted. human immunodeficiency virus (HIV): the virus that initially attacks the human immune system, causing HIV disease and eventually AIDS. human papillomavirus (HPV): an infection causing small lesions on genital skin; certain strains of this STD increase later risks of cervical cancer. lymphogranuloma venereum (LGV) (lim-fuh-gran-yuh-LOH-muh vuh-NEER-ee-uhm): contagious STD caused by several strains of chlamydia and marked by swelling and ulceration of lymph nodes in the groin. molluscum contagiosum (muh-LUH-skum kan-taj-ee-OH-suhm): a skin disease transmitted by direct bodily contact, not necessarily sexual, that is characterized by eruptions on the skin that appear similar to whiteheads, with a hard seedlike core. nonspecific urethritis (NSU) (yoor-uh-THRAY-tis): infection or irritation in the male urethra caused by bacteria or local irritants. opportunistic infection: a disease resulting from lowered resistance of a weakened immune system. perinatal: things related to pregnancy, birth, or the period immediately following the birth. perineal area (per-uh-NEE-al): the sensitive skin between the genitals and the anus. pubic lice: small insects that can infect skin in the pubic area, causing a rash and severe itching. retrovirus ( re-truh-VAHY-ruhs): a class of viruses that reproduces with the aid of the enzyme reverse transcriptase, which allows the virus to integrate its genetic code into that of the host cell, thus establishing permanent infection. rubber dam: a small square sheet of latex used to cover the vulva, vagina, or anus to help prevent transmission of HIV during sexual activity. scabies (SKEY-beez): a skin disease caused by a mite that burrows under the skin to lay its eggs, causing redness and itching; transmitted by bodily contact that may or may not be sexual. syndrome (SIN-drohm): a group of signs or symptoms that occur together and characterize a given condition. syphilis (SIF-uh-lis): sexually transmitted disease (STD) characterized by four stages, beginning with the appearance of a chancre. thrush: a disease caused by a fungus and characterized by white patches in the oral cavity. trichomoniasis (trik-uh-muh-NAHY-uh-sis): a vaginal infection caused by the Trichomonas organism. vulvovaginitis ( vuhl-voh-vaj-uh-NAHY-tis): general term for inflammation of the vulva and/or vagina. Western blot: the test used to verify the presence of HIV antibodies already detected by the ELISA. yeast infection: a type of vaginitis caused by an overgrowth of a fungus normally found in an inactive state in the vagina. Chapter 17 Sexual Dysfunctions and Their Treatment TOTAL TEACHING PACKAGE OUTLINE Lecture Outline Resources Reference Chapter 17: Sexual Dysfunctions and Their Treatment understanding sexual dysfunctions Teaching Suggestions: 1(A), 1(B), 6(B) Learning Objectives: #1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18 TYPES OF SEXUAL DYSFUNCTIONS Teaching Suggestions: 1(B), 4(A), 4(B), 4(C) Learning Objectives: #19,20,21,22,23,24 CAUSES OF SEXUAL DYSFUNCTIONS Teaching Suggestions: 5(A), 7(B) Learning Objectives: #25,26,27,28,29,30,31 TREATING SEXUAL DYSFUNCTIONS Teaching Suggestions: 6(A), 7(A) Learning Objectives: #32,33,34,35,36,37,38,39 BEHAVIORAL APPROACHES TO SEX THERAPY Teaching Suggestions: Learning Objectives: #40,41,42,43 LEARNING OBJECTIVES After reading this chapter, students should be able to: Describe the rates of, and complexities in defining a sexual dysfunction. Describe personal, professional, and cultural factors that influence perceptions concerning sexual dysfunction. List and describe mythical performance standards for each gender and the consequences of such standards. Describe cultural influences on “normalcy”, dysfunctions, and treatment. List and describe the three-phase model of sexual response. List rates of various labels for sexual dysfunctions. Describe three components of the dual control model relating to sexual response. Briefly describe factors and incidence of sexual dysfunction. List and describe three types of sexual interest/desire disorders. List and briefly describe two types of arousal disorders. Describe the physiological process of penile erection and the methods to determine if a dysfunction is physical. Briefly describe challenges faced by women concerning sexual arousal. Define vaginismus and briefly describe relational consequences of this dysfunction. Define dyspareunia and briefly describe potential causes of this sexual dysfunction. Define anodyspareunia and briefly describe potential causes of this sexual dysfunction. Describe the general rates and nature of orgasmic disorders. Describe rates of, and definitions used for premature ejaculation. Describe perceived physiological and behavioral causes of premature ejaculation. Briefly describe causes of, and behavioral changes seen in males with dyspareunia. Describe three generalizations regarding causes of sexual dysfunctions. Briefly describe when a physical exam is suggested for sexual dysfunction. Describe physical illnesses that can impact sexual functioning. Describe how the use of alcohol, illegal drugs, and medications can impact sexual functioning. Describe cultural and psychological factors that impact sexual performance. Briefly describe relationship factors that can influence sexual functioning. Describe some of the personal and professional challenges of treating sexual dysfunctions. Describe five medicinal treatments for sexual dysfunctions. Briefly describe two general types of biomedical devices used to treat sexual dysfunctions. List and describe five types of psychotherapeutic treatments for sexual dysfunctions. Describe reasons for a combination treatment approach for sexual dysfunctions. Briefly describe the general backgrounds and therapeutic goals of sex therapists. Describe challenges faced with finding a sex therapist. Briefly describe therapeutic concerns when treating sexual dysfunctions. List and describe five goals of behavioral sex therapy. Describe two self-help techniques used in treating sexual dysfunctions. List and describe four stages of partnership treatment for sexual dysfunctions. Define “sensate focus” and describe the three phases associated with this technique. Describe the rationale for the step approaches, culminating in sexual intercourse, for treating sexual dysfunctions. Briefly describe behavioral approaches for treating vaginismus. Briefly describe behavioral approaches for treating ejaculatory sexual dysfunctions. List and briefly describe two categories used to validate sex therapy treatments. Describe the general and research concerns regarding sexual dysfunction treatment effectiveness. Describe three main ethical issues for conducting sex therapy. Describe the three elements of AASECT’s code of ethics. CHAPTER OVERVIEW This chapter surveys sexual dysfunctions and the approaches that are used in sex therapy to treat them. Rather than simply labeling each dysfunction and explaining it separately, the chapter has integrated the coverage of each into the broader picture of sexual responsiveness and the total sexual relationship. It also explores the somewhat subjective nature of defining sexual dysfunctions and emphasizes that individual differences in the sexual response cycle are often perfectly normal. We have tried to reduce the number of times we use the somewhat intimidating term “dysfunction.” and are encouraging use of the term “dissatisfaction”. Students really should be helped to view these problems as being very treatable and as seeds for growth in relationships. The National Health and Social Life Survey (NHSLS) data confirm the rather high frequency with which people experience various forms of sexual dysfunction, making it clear how these frequencies differ by gender. In some ways, these figures may be reassuring to readers because dysfunctions are obviously not rare in the population. They may also raise the issue of whether some degree of difficulty in sexual functioning from time to time may actually represent a rather normal state for people. This chapter focuses on the various causes of sexual dysfunctions. In recent years, there has been greater emphasis on potential organic conditions that can manifest themselves in sexual difficulties, including the effects of alcohol, other drugs, and certain medications. On the other hand, it is still a safe assumption that many sexual disorders of this sort are caused by the vicious circle of anxiety and fear of failure generating lack of responsiveness, or by difficulties within a relationship. All of these factors are discussed. Individual differences in sexual responsiveness should be considered to determine whether a true dysfunction is present. Every culture sets its own sexual performance standards, although sometimes some may be unrealistic. These standards may become debilitating pressures and unfair expectations for men and women. Scientific terminology dictates that sexual dysfunctions may be lifelong or acquired, generalized or situational. Sexual dysfunctions represent disruption with one or more of the three major phases of the human sexual response cycle: desire, arousal, or orgasm. Individuals who have impaired desire for sexual gratification may be experiencing hypoactive sexual desire disorder (HSDD). Sexual aversion disorder is characterized by fears about, and avoidance of sexual activity. Arousal problems are expressed as male erectile disorder, involving interference with penile erection, or female sexual arousal disorder, characterized by absence of vaginal lubrication and other signs of sexual excitement. Vaginismus is caused by involuntary spasms of the outer vaginal musculature, resulting in difficulty with insertion into the vagina. Pain associated with sexual activity is called dyspareunia and anodyspareunia when considering pain with anal penetration. Premature ejaculation in males may well be a conditioned response and is the most common sexual dysfunction in men. Sexual dysfunctions may have causes at several different levels, involving predisposing factors, precipitating factors, and/or maintaining factors. Causes may also be biological or medical (organic), substance-induced, psychological, or social/relational. Performance pressures and difficulties in relationships (such as poor communication) are often at the root of sexual dysfunctions, although possible medical causes must first be investigated. Behavioral techniques are a widely used treatment by sex therapists, although medical treatments are becoming more common. Oral medications, such as Viagra, or injection and suppository applications inserted directly into the penis are sometimes used to treat erectile disorder. Medications are also used to treat premature ejaculation and hypoactive sexual desire. Psychotherapy, couples therapy, hypnosis, and group therapy have all been used to treat sexual dysfunctions. The ethics, training standards, and certification standards for sex therapists are still being developed by national professional organizations. Behavioral sex therapy helps dysfunctional individuals to unlearn ineffective behaviors and replace them with positive, effective patterns of sexual interaction. There is debate about the actual effectiveness of sex therapy, and methods have been classified as well-established or probably efficacious in terms of their effectiveness. Sex therapy raises certain ethical issues and dilemmas, and specific guidelines have been developed for the ethical conduct of therapists. TEACHING SUGGESTIONS 1. Discussion Topics A) Discuss the myths regarding sexual performance standards. Ask the class if they think these myths still exist. Why or why not? Also ask them to define what the elements of a good sexual encounter would be. B) Tell students about the various causes of sexual dysfunctions mentioned in the text, which specifically discuss this issue. Then ask students to describe some emotional or psychological factors that could have an influence on sexual functioning. Include factors for both males and females. Some examples could be past sexual experiences, drinking, anger at a partner, or suspicion of a partner’s commitment. 2. Role-Plays Have students role-play one or more of the following scenarios: A) Three males are in a locker room discussing their anticipated sexual performances during the upcoming weekend. One of the males knows that he has difficulty maintaining an erection. How would he be reacting? B) A husband and wife are discussing their different desires about how often they make love. Remember the chapter on communications. How could they resolve this issue? C) One woman is telling another woman how difficult it is to continue to fake orgasms with her husband. She pretends because she doesn’t want to hurt his feelings. What would her friend say? D) A therapist is treating a married couple for a sexual dysfunction problem and is told privately by the wife that she had contracted an STD during an affair. The therapist is discussing this issue with a colleague. 3. Case Study Questions In “Cross-Cultural Perspective—Sexual Dysfunction in Other Cultures” (in the main text), a comparison of attitudes is made in regard to what is considered “normal” sexual relationships in other cultures. Have students read the case study and discuss: The lack of significance given to female sexual enjoyment. The use of aphrodisiacs, herbs, acupuncture, etc. to restore sexual functioning. Do people in this culture use anything to enhance or restore sexual functioning? The difficulties that a traditional sex therapist may have in treating people from other cultures. Essays/Papers Have students write about one or more of the following topics: A) Why do you think women report more sexual problems than men except in the areas of performance anxiety and reaching orgasm too early? B) Do you feel that labels such as impotent, preorgasmic, or sexual aversion are helpful when defining a sexual dysfunction, or do they tend to make the problem seem overwhelming? C) How do you believe you would respond if your partner had a sexual problem? How would you feel if you realized you had a sexual dysfunction? 5. Project A) Objective: To have students think about all of the aspects of a sexual dysfunction. Method: Tell students to imagine that they or a partner are experiencing a sexual dysfunction. Have them pick one. Their project is to develop a plan of action for dealing with the difficulty. This plan needs to include resources, a therapist, and other information that will help. Have them describe how they would go about finding a therapist. Whom would they ask for referrals? What degrees would they want the therapist to have? What experience? Does gender make a difference? Would they use self-help approaches? What specific treatments would they expect the therapist to use? What other information would they want to obtain in order to deal with their dysfunction? Ask students to write up their plan of action. They can either turn it in as a written assignment or present it to the class. Upon completion: Students will have developed resources and thought out an approach to dealing with a sexual dysfunction. This plan could help them in the future. 6. Guest Speakers A) Ask a sex therapist to come and speak to your class. A urologist may also be a good speaker to discuss various prosthetic devices. Another possible speaker could be someone with a spinal cord injury. This might be very interesting in terms of the class hearing from someone who has a sexual dysfunction as a result of a physical injury. 7. SexSource Video Bank The SexSource video bank provides an excellent array of short videos that may serve as discussion starters. In order to elicit the best responses, it is advisable to pair students in groups of two for “pair sharing.” Give them the initial starter questions below, and then show the videos after some initial discussion. Instructors should preview videos for time and content. Additionally, you may want to download clips prior to class to ensure they are ready for viewing regardless of network connectivity. All video clips may be found at: http://www.mhhe.com/sexsource Taking a Sexual History video clip – Ask paired students: What would a session with a sex therapist entail? How could an individual’s sex life benefit from therapy? Would you be willing to go for sex therapy? Why or why not? In this video, a therapist is taking a detailed sexual history of a man with erectile difficulties. Note how the therapist explains how his questions and the answers he gets provide clues as to where the sexual difficulty may lie. Viagra and Sexual Pharmacology video clip – Ask paired students: What does Viagra do? How prevalent is its use in our society and what does this say about our society? This video clip discusses the somewhat “accidental” discovery of Viagra™ (sildenafil) as a treatment for erectile dysfunction. It was originally being tested as a drug for heart disease. Since that discovery, more medications have been developed that can enhance erection. Viagra™ has been tried with women as well but has not been as effective. This may be because men associate sexual desire more directly with erection of the penis. While Viagra™ does increase circulation of blood to the penis, therefore assisting with the quality of erection, it does not increase sexual desire per se. Obviously, if a man has been worried about getting erections and this anxiety has interfered with the mechanisms of erection, the confidence that Viagra™ may generate may also make him feel more relaxed and therefore allow him to feel more sexual desire GLOSSARY acquired dysfunction: a difficulty with sexual functioning that develops after some period of normal sexual functioning. behavior therapy: therapy that uses techniques to change patterns of behavior; often employed in sex therapy. dyspareunia (dis-puh-ROO-nee-uh): recurrent or persistent genital pain related to sexual activity. female sexual arousal disorder: difficulty for a woman in achieving sexual arousal. hypoactive sexual desire disorder (HSDD): loss of interest and pleasure in what were formerly arousing sexual stimuli. impotence: difficulty achieving or maintaining erection of the penis. lifelong dysfunction: a difficulty with sexual functioning that has always existed for a particular person. male erectile disorder: difficulty achieving or maintaining penile erection (impotence). normal asexuality: an absence or low level of sexual desire, which is considered normal for a particular person. premature ejaculation: difficulty that some men experience in controlling the ejaculatory reflex, resulting in rapid ejaculation. preorgasmic: a term that has been applied to women who have not yet been able to reach orgasm during sexual response. sensate focus: an early phase of sex therapy treatment in which the partners pleasure each other without employing direct stimulation of sex organs. sex therapist: a professional trained in the treatment of sexual dysfunctions. sexual aversion disorder: an avoidance of or exaggerated fears toward forms of sexual expression. sexual surrogates: paid partners used during sex therapy with clients lacking their own partners; only rarely used today. spectatoring: term used by Masters and Johnson to describe self-consciousness and self-observation during sex. systematic desensitization: step-by-step approaches to unlearning tension-producing behaviors and developing new behavior patterns. Vaginismus (vaj-uh-NIZ-muhs): involuntary contraction of the outer vaginal musculature when vaginal penetration is attempted. Instructor Manual for Sexuality Today Gary Kelly 9780078035470
