What does mental health have to do with HIV prevention?

As much as the HIV epidemic has changed over the past 20 years, most reasons for continued high-risk sexual behavior have remained very much the same. Some factors that contribute to these behaviors are: loneliness, depression, low self-esteem, sexual compulsivity, sexual abuse, marginalization, lack of power and oppression. These issues do not have quick fixes. Addressing these basic issues requires time and effort and may extend beyond the capabilities of most HIV prevention programs.

One thing we have learned from HIV prevention research is that "one size does not fit all." Programs need different components to address the different needs of clients. Increasing knowledge, skills building and increasing access to condoms and syringes are good methods but don't work for everyone or on their own. For many, the barriers to behavior change are mental health problems. This fact sheet focuses on non-acute mental health issues and does not address the effect of severe mental illness or brain disorders on HIV prevention.

What people do and what they experience affects their mental health. Substance use and abuse, discrimination, marginalization and poverty are all factors that impact mental health and, in turn, can place people at risk for HIV infection.

Do mental health issues affect HIV risk?

Yes. The decision to engage in risky sexual or drug-using practices may not always be a consciously made "decision." Rather, it is based on an attempt to satisfy some other need, for example:

LOW SELF-ESTEEM. For many men who have sex with men (MSM), low self-esteem and internalized homophobia can impact HIV risk-taking. Internalized homophobia is a sense of unhappiness, lack of self-acceptance or self-condemnation of being gay. In one study, men who experienced internalized homophobia were more likely to be HIV+, had less relationship satisfaction and spent less social time with gay people. 1

Male-to-female transgender persons (MTFs) identify low self-esteem, depression, feelings of isolation, rejection and powerlessness as barriers to HIV risk reduction. For example, many MTFs state that they engage in unprotected sex because it validates their female gender identity and boosts their self-esteem. 2

ANXIETY AND DEPRESSION. Young adults who suffer from anxiety and depression are much more likely to engage in high-risk activities such as prostitution, both injection and non-injection drug use and choosing high-risk partners. One study that followed inner-city youths for several years found that change in risk behavior was not associated with knowledge, access to information, counseling or knowing someone with AIDS. Reducing symptoms of depression and other mental health issues were, however, associated with reductions in HIV-related risk behaviors. 3

SEXUAL ABUSE. Persons who experience incidents of sexual abuse during childhood and adolescence are at a significantly higher risk of mental health problems and HIV risk behavior. A study of adult gay and bisexual men found that those who had been abused were much more likely to engage in unprotected anal intercourse and injecting drug use. 4

For many women, sexual abuse is combined with physical and/or emotional abuse in childhood or adolescence. HIV risk is only one of the consequences of this abuse for women. Women may turn to drug use as a way of coping with abuse experience(s). They may also have difficulty adjusting sexually, causing difficulty negotiating condom use with partners and increasing the likelihood of sexual risk-taking. 5 Women who have been abused have higher rates of sexually transmitted diseases (STDs) including HIV. 6

POSTTRAUMATIC STRESS DISORDER (PTSD). PTSD may account for high sexual risk-taking activities. In one study among female crack users in the South Bronx, NY, 59% of women interviewed were diagnosed with PTSD due to violent traumas such as assault, rape or witness to murder, and non-violent traumas such as homelessness, loss of children or serious accident. 7 A national study of veterans found that substance abusers who suffered from PTSD were almost 12 times more likely to be HIV-infected than veterans who were not substance abusers nor suffering from PTSD. 8

What factors impact mental health? Many persons who suffer from mental health problems turn to substance use as a means of coping. Substance use has been shown to decrease inhibitions and impair judgment, which can contribute to HIV risk-taking. Injection drug users (IDUs) who suffer from depression are at higher risk for needle sharing. 9

Environmental factors such as poverty, racism and marginalization can lead to mental health problems such as low self-esteem which can in turn, lead to substance use and other HIV risk behaviors. Inner-city young adults with high rates of HIV risk behaviors also experience higher rates of suicidality, substance misuse, antisocial behavior, stressful events and neighborhood murders. 10

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What's being done?

Addressing mental health issues does not only mean getting clients to see an individual counselor or therapist. Community-level and structural programs can also address mental health needs. For example, a program can hire a trained facilitator and offer support groups for survivors of sexual abuse. Open houses or drop-in centers where individuals can meet each other can serve to combat loneliness and depression. Offering mobile vans that deliver syringe exchange as well as clothing or food can reach isolated groups that are at high risk for mental health problems and HIV.

The Bodyworkers Program in New York, NY, provides MSM sex workers with free HIV prevention and mental health counseling, peer counseling and access to medical services. Male body workers, escorts, street hustlers, porn stars, go-go dancers and others cited several mental health issues that are barriers to accessing prevention and medical services. They are: mistrust, shame, isolation, fear of personal relationships, sexual compulsivity, depression, low self-esteem, substance abuse and a history of physical/sexual abuse. 11

The HAPPENS (HIV Adolescent Provider and Peer Education Network for Services) Program in Boston, MA, provides a network of youth-specific care to HIV+, homeless and at-risk youth. The program conducts street outreach, offers individual HIV risk reduction counseling and links youth to appropriate social, medical and mental health services. All health care visits include a mental health intake and mental health services are offered both on a regular basis and at times of crisis. 12

A program in New Haven, CT, used a street-based interactive case management model to reach drug-using women with or at risk for HIV. Case managers traveled in mobile health units to provide intensive one-on-one counseling on-site. Counseling often included discussions among members of the client's family and peers. Case managers also provided transportation, crisis intervention, court accompaniment, family assistance and donated food and clothing. 13

What are the implications for prevention programs?

Persons working in HIV prevention need to be aware of the close association between mental health, social and environmental factors and an individual's ability to make and maintain behavior changes. Prevention program staff should be trained to look for and identify mental health problems in clients. If mental health staff are not available on-site, programs can provide referrals to counselors as needed. Some service agencies have integrated mental health services into their overall services and can provide counseling as part of their prevention interventions.

Mental health issues are often overlooked because of stigma on an institutional and individual level. These issues may vary across communities and by geographic region. Addressing mental health problems is an integral part of health promotion and should be a part of HIV prevention. It is not about labeling or putting people down, but about providing accurate diagnoses and treatments for mental and physical health.

Read: Everything you need to know about AIDS testing

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Says who?

1. Ross MW, Rosser BR. Measurement and correlates of internalized homophobia: a factor analytic study. Journal of Clinical Psychology. 1996;52:15-21.

2. Clements-Nolle K, Wilkinson W, Kitano K. HIV Prevention and Health Service Needs of the Transgender Community in San Francisco. in W. Bockting & S Kirk editors: Transgender and HIV: Risks, prevention and care. Binghampton, NY: The Haworth Press, Inc. 2001; in press.

3. Stiffman AR, Dore P, Cunningham RM et al. Person and environment in HIV risk behavior change between adolescence and young adulthood. Health Education Quarterly. 1995;22:211-226.

4. Bartholow BN, Doll LS, Joy D, et al. Emotional, behavioral and HIV risks associated with sexual abuse among adult homosexual and bisexual men. Child Abuse and Neglect. 1994;9:747-761.

5. Miller M. A model to explain the relationship between sexual abuse and HIV risk among women. AIDS Care. 1999;1:3-20.

6. Petrak J, Byrne A, Baker M. The association between abuse in childhood and STD/HIV risk behaviors in female genitourinary (GU) clinic attendees. Sexually Transmitted Infections. 2000;6:457-461.

7. Fullilove MT, Fullilove RE, Smith M, et al. Violence, trauma and post-traumatic stress disorder among women drug users. Journal of Traumatic Stress. 1993;6:533-543.

8. Hoff RA, Beam-Goulet J, Rosenheck RA. Mental disorder as a risk factor for HIV infection in a sample of veterans. Journal of Nervous and Mental Disease. 1997;185:556-560.

9. Mandel W, Kim J, Latkin C, et al. Depressive symptoms, drug network, and their synergistic effect on needle-sharing behavior among street injection drug users. American Journal of Drug and Alcohol Abuse. 1999;25:117-127.

10. Stiffman AR,Doré P, Earls F, et al. The influence of mental health problems on AIDS-related risk behaviors in young adults. Journal of Nervous and Mental Disease. 1992;180:314-320.

11. Baney M, Dalit B, Koegel H et al. Wellness program for MSM sex workers. Presented at the International Conference on AIDS, Durban, South Africa. 2000. Abstract #MoOrD255.

12. Woods ER, Samples CL, Melchiono MW, et al. Boston HAPPENS Program: a model of health care for HIV-positive, homeless and at-risk youth. Journal of Adolescent Health. 1998;23:37-48.

13. Thompson AS, Blankenship KM, Selwyn PA, et al. Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. Journal of Community Health. 1998;23:419-421.

Prepared by Jim Dilley, MD, Pamela Decarlo, AIDS Health Project, CAPS, September 2001

Thanks to the nerds who created the Internet, you no longer need to visit the adult bookstore incognito to get your smut on. But is easily accessible porn a good thing?

"Bob" 31, didn't realize he had a porn problem. Until it cost him his wife.

His fixation began with softcore magazines when he was a teenager, and grew slowly. But it didn't become a full-blown addiction until he discovered Internet pornography, by which time he had already gotten married and had a young daughter. "I started isolating myself-because I wanted to spend time on the computer," he recalls. "My waking hours were ruled by it. Porn dominated my life:

Sometimes he'd pull exhausting all-nighters surfing the Web for raunchy material, leaving him bleary-eyed the next day and barely able to accomplish anything at his job as an Internet marketing specialist in California. Soon Bob became distant from his spouse, and communication started breaking down, putting a strain on his marriage. His wife told him he had a sexual addiction. But he paid no attention, and she eventually left him.

Bob's case may be extreme, but it's not altogether uncommon. Today, nearly 75% of U.S. households have Internet access. Translation: Three-quarters of American homes can download porn. Roughly one-quarter of all Web searches are porn-related, and porn sites (of which 1,000 new ones are created daily) receive millions of hits each day. Porn itself has become a multibillion-dollar industry.

"Now you can get [porn] in the privacy, of your own home, without sanction;' says Julie Albright, Ph.D., a researcher on Internet sex and a sociologist at the University of Southern California. "Imagine a schoolteacher being seen walking into the town's triple-X bookstore--the ultimate taboo. Now he doesn't have to"

This easy access is making sex addiction much more common, some psychologists say. They claim that adult entertainment can impact society negatively by hindering men's relationships with women and leading to obsessive, self-destructive behavior. A study published in Professional Psychology found that as many as 7.1% of men now say they spend up to 30 hours a week surfing for porn.

Porn-industry sources counter that the rapid growth of porn is merely the result of meeting demand. They also claim that pornography can serve as a healthy release and provide greater intimacy, between men and women.

Both are probably right--which is why the issue can be so confusing.

THE RISE OF PORN

People have craved sexually explicit distractions practically since cave dwellers first took charcoal to a rock wall. In ancient Greek times, they turned to pornographos--"writing about prostitutes: These days, Webster's defines pornography as "sexually explicit pictures, writing, or other material whose primary purpose is to cause sexual arousal."

The current boom in adult entertainment can be traced to the late 1960s and early '70s, when porn was legalized in Denmark and stag movies motivated American men to buy home projectors and hang sheets in their basements. Breakthrough films such as Deep Throat (1972) and Debbie Does Dallas (1978) put X-rated awareness on the mainstream map--and drew the ire of the feminist movement, which argued that adult films objectified women. During the '80s, the advent of video made producing adult movies cheaper and allowed people to watch them discreetly at home. And now, since the popularization of the Web in the mid-'90s, access has never been easier. Broadband Internet and on-demand video have practically made porn an upstanding member of pop culture. Today Jenna Jameson can share talk-show couch time with Jennifer Aniston.

Adam Glasser, a porn star/director known professionally as Seymore Butts, says the reason adult entertainment hit the mainstream is simple: Sex sells. Producers of the stuff are simply feeding demand. "Even on broadcast TV, people are trying to find creative ways to titillate the audience; he notes. "Now you can see Dennis Franz's ass or, on Joe Millionaire, captions like 'slurp, slurp:"

Glasser is regarded as a trailblazer in the "gonzo porn" genre--adult movies with almost zero plot (meaning millions of men no longer have to wear down their fast-forward button). He also stars in Family Business, the Showtime reality show that chronicles his life in the porn biz. "Sex wouldn't be so available if people didn't want it," he adds.

THE PORN IDENTITY

But it was just such easy availability that ultimately did Bob in. "The Internet was really the downfall for me," he says. "My senses dulled, and I stopped focusing on my day-to-day life. I gave up my interests, my friendships: With his marriage over, "All of a sudden, I woke up and saw my life in ruins."

"Weston, who runs no-porn.com, a Web discussion board for sex addicts that receives more than 1,000 visitors daily, says he, too, found the Internet irresistible. "I even downloaded porn at work," he recalls, "which is professional suicide. I was never fired, or even accused of using porn, but I wasn't as valuable to my company as I could have been."

His situation at home also deteriorated. "I felt like I was living a secret life; he says. "As a father, I was distant and demanding. The irony is I thought I was a great husband and father. I've learned that I was mistaken."

These experiences follow an almost textbook storyline for sexual addiction. What begins with mild curiosity snowballs into such an obsession that addicts start isolating themselves, falling deeper into their dependency. Sex addiction typically begins when the individual has specific sexual experiences that form his sexual-arousal template. "They create a life based around secrecy and shame," says Charlie Walker, Ph.D., vice president of operations at the CompassPoint Addiction Foundation, a research center which specializes in treating various addictions, in Scottsdale, Ariz. "They don't need anyone else for gratification." Addicts also constantly try to up the ante each time they indulge. Sexual compulsivity is typically a disease that escalates over time. "It's like when someone starts off needing a beer a day adds Walker, "then works up to a whole case: They experience a continuing escalation in their behaviors, becoming desensitized to images that were once stimulating. The sex addict requires increasingly more provocative pictures in the same way the alcoholic needs to increase his intake to get the same feeling.

Walker says porn becomes an addiction when someone begins ordering his life around it, often to the exclusion of everything else. He can't resist sexual impulses and easily loses track of time when surfing adult content. Porn can also hinder relationships, segregate addicts from friends, colleagues, and especially significant others, and create unrealistic sexual expectations of women.

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PRESS "PLAY" FOR FOREPLAY

This isn't to say that everyone who enjoys porn is destined to become an addict. "There are people who use pornography as part of their arousals says Walker, "but it does not become an organizing principle of their sexuality--just like there are people who can drink responsibly:

Glasser claims his movies can actually be sexual aids for couples. "People can learn not only about technique, but they learn about their bodies in general," he says. "I get letters from people all the time thanking me for helping open their eyes about their sexuality." He cites one such letter from a woman married 27 years, whose husband, after watching a Seymore Butts film, "finally found her G-spot?"

James, a 33-year-old from D.C., says he uses adult movies--on video and downloaded from the Internet--as foreplay; "On occasion, my wife and I like to watch porn to intensify our sexual experience;" he says. "It's a quick way to get aroused, or even get us back on track for round two."

Glasser argues that there's a problem when guys watch adult videos and don't tell their significant others--a sign of relationship issues that run deeper than an interest in pore. "You've got to ask, Why does this guy feel like he's forced to watch it behind closed doors? That's a problem right there. Communicating about sex and sexuality is almost as important as having sex regularly with someone you love."

True, but the reality is that porn is mostly a guy thing. According to the Web resource Internet Filter Review, 72% of" all visitors to porn sites are male. And if a guy does communicate with his girlfriend or wife about porn, and she wants no part of it, he may very well continue to watch in secret.

PORN-FREE

For guys whose obsessions become too difficult to manage, new sex-addiction treatment groups are more widely available. I. David Marcus, a psychotherapist in San Jose, Calif., says anyone who spends several hours a week pornicating should question whether he's becoming dependent.

Take away the temptation by installing SPA-M-blockers for your e-mail, he says, and software that will log you off the Web after an hour or two. If the problem spirals out of control, talk to a friend, seek help, or attend a group session like Sex Addicts Anonymous (sexaa.org). However you do it, get away from that computer and take back your life.

Bob finally reds like he has come to terms with his addiction. "I realized pornography wasn't my friend anymore," he says. He sought counseling and joined a 12-step group for sex addicts. Now he has a new job and a "zero-tolerance policy" for himself regarding porn. "I'm just more focused on my goals in life," he says. "I have far more self-respect. I have the shame of the past, but I don't carry the shame and guilt of that lifestyle any longer."

STUCK ON SMUT?

Are you a porn addict? Find out: Close that issue of Happy Mammaries, get your right hand off the mouse, your left hand out of your pants, and take this quiz (adapted from "The Sex Addiction Screening Test" by Patrick Carnes. Ph.D.). This test is not a substitute for a complete assessment from a professional therapist versed in treating sexually compulsive behaviors. For the original test. visit sexhelp.com

Which of the following applies to you and porn?

1. I often can't resist my impulse to view it.

2. I often spend more money, or time, on it than planned.

3. Many times I've tried--without success--to reduce or step altogether my porn usage.

4. I spend excessive time looking for it, viewing sexual materials, or being engaged in sexual activities.

5. I'm constantly preoccupied with it.

6. Sometimes, instead of meeting family, work, or social obligations. I'm using it.

7. I continue using porn, even though I'm aware my habit is taking a personal, financial, and maybe even physical toll on my life.

8. The more I use it, the more I need to up the thrill or risk level to get the same satisfaction.

9. I'm passing up potential work and social opportunities for porn's sake.

10. I become upset, stressed, or irritable when I'm unable to access it.

Summary: If you answered "yes" to four or more of these statements, consider seeking professional treatment from a therapist trained in treating sexually compulsive behaviors.

Contributor Greg Melville teaches journalism at St. Michael's College in Burlington. Vt.

 

HIV/AIDS sufferers and children whose families are infected with the virus may suffer mental health problems arising directly or indirectly from living with the virus. HIV infected people have to deal with the stigma attached in some communities to being HIV positive. Partners, family and friends, may experience psychological stress from having to nurse sick relatives and deal with multiple deaths.

Antiretroviral therapy can reduce the prevalence of HIV related dementia by stopping the spread of infection.

Mental illness can arise as a direct consequence of HIV infection. For example, HIV enters the central nervous system in the early stages of infection and a significant number of people with HIV develop a reduction or impairment of the brain's cognitive function, such as HIV dementia or minor-cognitive disorder. Impairment increases as the disease progresses. Antiretroviral therapy can reduce the prevalence of HIV related dementia by stopping the spread of infection.

 

Mood disorders are common in people with HIV/AIDS:

• In three South African studies, major depression was diagnosed in between 35 and 38 percent of HIV/AIDS sufferers.
• In one study, an additional 22 percent were diagnosed with dysthymia - a form of mood disorder characterized by a lack of enjoyment in life.
• 'AIDS mania' (usually featuring inappropriate excitement) appears in the late stages of AIDS and is estimated to occur in around 1.4 percent of cases.

People who abuse substances and suffer from severe mental illness are at increased risk of infection. Moreover, some HIV/AIDS sufferers may be at risk of becoming substance abusers or developing severe mental illness. Infected people may turn to alcohol and drugs to psychologically manage their disease. Psychosis may occur in late-stage AIDS, though this is rare.

Coping with being HIV positive can be made more difficult by the reactions of communities and even friends and family. People who are rejected or discriminated against may become more depressed. This can result in a more rapid progression of the disease. Even where people have not been discriminated against, fear of rejection and discrimination can lead to them being unable to live a normal life.

 

Many children will lose their parents to HIV/AIDS. This is not only traumatic in itself but many of these children may not be integrated into new families. This could have devastating consequences for their mental health, both as children and as adults:

• In a Zambian study, 82 percent of people who care for children of AIDS sufferers noted changes in the children's behavior during their parents' illness. Children stopped playing, became worried, sad and too tired to help at home.
• In Uganda, children were reported to feel despair or anger and were scared their parents would die. Once the parent died, orphans in Uganda and Mozambique suffered more depression.
• In Tanzania, 34 percent of orphans had contemplated suicide.
• In South Africa, AIDS orphans experienced more physical symptoms and were likely to have nightmares. 73 percent suffered from posttraumatic stress disorder.
• Because of the ongoing presence of HIV/AIDS within families and communities, these traumatic consequences may occur many times over.

Mental health problems are a critical aspect of the HIV/AIDS epidemic for both infected and affected people. As mental health problems often hinder effective adherence to antiretroviral treatment, it is necessary to include mental health care as part of HIV/AIDS treatment. Equally, mental health practitioners need to understand that patients increasingly have HIV/AIDS-related symptoms.

Programs are needed to deal with mental health in vulnerable or orphaned children. While work with children who have developed mental health problems is vital, the most important thing is preventing children from developing mental health problems. Families should be supported to take in and care for orphans, whilst orphans themselves need help to adjust to new and sometimes difficult situations.

Mr. Freeman is associated with the Social Aspects of HIV/AIDS and Health (SAHA) Human Sciences Research Council in South Africa.

Disinhibited social engagement disorder, like its cousin reactive attachment disorder, is a trauma disorder of infancy or early childhood. Both disorders are caused by severe neglect resulting in unmet physical and emotional needs. As a result of such extreme neglect, the infant does not form an attachment to a caregiving adult. Without this necessary bond, the child doesn’t develop a sense of security, safety, and trust that paves the way for healthy adjustment and social relationships, and either reactive attachment disorder or disinhibited social engagement disorder can follow (Reactive Attachment Disorder (RAD) Symptoms).

Both trauma disorders are rare. Less than 10 percent of infants who experience grave neglect develop reactive attachment disorder, a condition that causes withdrawal, avoidance, and an inability to seek or accept comfort. In disinhibited social engagement disorder, experienced by less than 20 percent of dangerously neglected infants, children seek affection and attachment wherever they can and from whomever they can.

Disinhibited Social Engagement Disorder in the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) from the American Psychiatric Association (2013) provides the official criteria necessary for an infant or young child to receive a diagnosis of disinhibited social engagement disorder. The primary criterion for disinhibited social engagement disorder is that the child purposely and indiscriminately approaches and interacts with unfamiliar adults. Further, the young child shows

• No hesitation in approaching and interacting with strangers
• Inappropriately familiar verbal or physical behavior with strangers
• No type of checking back with the caregiver after wandering off
• Willingness to go off with anyone who approaches

According to the DSM-5, this trauma disorder can only be diagnosed between the developmental ages of nine months and two years. If disinhibited social engagement disorder hasn’t manifested by age two, it is highly unlikely that it will develop. That said, the effects of non-attachment are stable over time and affect children of all ages.

Disinhibited Social Engagement Disorder in Specific Age Groups

No matter the age of the child disinhibited social engagement disorder involves a complete lack of hesitation in approaching, engaging with, and/or going off with adults whether known or unknown. Other behaviors are added as children develop.

• Toddlers don’t check back with the caregiver as is typical in this stage of development
• Preschoolers begin to display blatant attention-seeking behavior and intrusiveness
• Elementary-aged children violate boundaries and act in overly familiar ways
• In teens, inappropriate and indiscriminate behaviors often lead to conflicts and superficial relationships

Behaviors Associated with Disinhibited Social Engagement Disorder

The child with disinhibited social engagement disorder seeks attachment and bonding from anyone, anywhere, at any time. The behaviors that result from this are outside of socially accepted norms and ironically end up driving others farther away rather than fostering bonding and attachment.

• Exaggerating needs, sometimes dramatically
• Dependence
• Neediness
• Being overly clingy/affectionate
• Developmentally inappropriate childishness/immaturity
• Becoming easily upset with disruptions in routine
• Showing distress for no apparent reason
• Intense, frequent romantic crushes
• Sexual promiscuity
• Watchful, anxious demeanor
• Impatience
• Lying
• Manipulation
• Quickness to anger
• Aggression
• Difficulty making friends

This behavior can be quite challenging to deal with. It can mimic such other disorders such as oppositional-defiant disorder or conduct disorder. Disinhibited social engagement disorder, though, is unique in that severe neglect and lack of attachment must be present before the age of two.

It can be helpful to remember that the behavior, while maladaptive, has a purpose: to draw people close in order to feel the safety, security, trust, and affection that comes with attachment. Treating disinhibited social engagement disorder is possible. As in treating reactive attachment disorder, establishing a safe, nurturing, secure environment that fosters trust can gradually and drastically reduce the effects of disinhibited social engagement disorder.

article references

There has been a tremendous amount of attention paid of late to the potential usefulness of pharmaceutical options for Female Sexual Dysfunction (FSD). However, little, if no attention, has been paid to non-pharmaceutical options for treating organically based FSD. Up to now, the only option that has been investigated for women is a clitoral therapy device called the EROS-CTD. This device actually creates a gentle suction over the clitoris and the surrounding tissue, with the intention of increasing blood flow to the area and enhancing lubrication and sensation.

The principle behind this device is the idea that clitoral stimulation and tumescence (engorgement due to increased blood flow) play an important role in female sexual arousal and overall sexual satisfaction. In normally responsive females, engorgement occurs when sexual arousal results in smooth muscle relaxation and arterial wall dilation within the clitoris. The CTD device was designed to not only increase blood flow and therefore sensation and lubrication, but also to potentially serve a therapeutic purpose, enhancing overall clitoral blood flow over time.

The EROS-CTD was evaluated in a two-center pilot study of 25 patients, 8 pre-menopausal and 6 post-menopausal women with complaints of Female Sexual Arousal Disorder (FSAD), and 4 pre-menopausal and 7 post-menopausal women with no sexual function complaints. The goal was to evaluate the safety and efficacy of the EROS-CTD treatment for enhancing subjective arousal in women with sexual arousal disorder in the areas of genital sensation, vaginal lubrication, ability to reach orgasm and general sexual satisfaction.

A complete medical history and physical examination was performed on each patient and a brief psychosexual history was taken by a sex therapist to be certain that there was not a primary emotional or relational basis for the woman's complaint. This was because no drug therapy or device will prove useful to a woman who's sexual function complaints are based on relational or emotional factors. Patients who had a history of depression, unresolved sexual abuse, hypoactive sexual desire disorder (not caused by sexual function complaints), diabetes, dyspareunia or certain other risk factors were excluded from the study.

Patients were asked to use the EROS-CTD Treatment in the privacy of their home with or without a partner. For every home session, each patient was asked to fill out the Female Intervention Efficacy Index (FIEI), (Chronbach's Alpha Coefficient .81), developed by Berman and Berman, measuring subjective reports of changes in lubrication, sensation, orgasm and sexual satisfaction following use of the EROS-CTD.

Results after using device	Sensation		Orgasm		Sexual Satisfaction		Lubrication
	Women w FSAD (%)	Women w/o FSAD (%)	Women w FSAD (%)	Women w/o FSAD (%)	Women w FSAD (%)	Women w/o FSAD (%)	Women w FSAD (%)	Women w/o FSAD (%)
More than Before	100	78	56	40	94	20	81	40
Same as Before	0	22	44	60	6	80	13	50
Less than Before	0	0	0	0	0	0	0	0
Couldn't Tell, Partner Yes							6	10

According to these preliminary results, the EROS-CTD Treatment may prove useful in treating sexual arousal complaints including reduced genital sensation, diminished vaginal lubrication, reduced sexual satisfaction, and diminished ability to achieve orgasm. There was no evidence of clitoral trauma, bruising or irritation as observed during the final physical examination on any of the patients in the study. This is a small convenience sample of women and results can not be generalized to the larger population.

Questions of whether ongoing use of the EROS-CTD Treatment will improve overall blood flow to the clitoral area or orgasmic response are yet to be determined. Longitudinal studies with larger samples are necessary to adequately determine the effectiveness of this intervention. However, the implications for non-drug therapies are significant. If these preliminary results are supported by larger scale studies, the EROS-CTD, developed by UroMetrics, Inc., may be the first of an array of non-pharmacological options available to women who either don't or can't take medication to treat organically-based sexual complaints.

Sources:

Billups, K., Berman, L., Berman, J., Metz, M., Glennon, B., & Goldstein, I. A new pharmacological vacuum device to enhance clitoral engorgement for treatment of female sexual arousal disorder. Journal of Sex Education and Therapy (in submission).

Berman, L., Berman, J., Sachin, S., Goldstein, I. Effects of Viagra as Assessed by the Female Intervention Efficacy Index (FIEI), Journal of Sex Education in Therapy (in submission)

Berman, L, & Berman, J. Viagra and beyond: Where sex educators and therapists fit in from a multidisciplinary perspective. Journal of Sex Education and Therapy (in press)

Diederichs, W., Lue, T., and Tanagho, E.A. Clitoral Responses to central nervous stimulation in dogs, IJIR, 3:7, 1991.

Kohn, I, Kaplan, S. Female sexual dysfunction, what is known and what remains to be determined. Contemporary Urology, September, 1, Vol. 11, No. 9, 54-72.

Park, K., Goldstein, I., Andry, C., Siroky, M.B., Krane, R.J., Azadozi, K.M., Vasculogenic female sexual dysfunction: The hemodynamic basis fore vaginal engorgment insufficiency and clitoral erectile insufficiency, IJIR, 9:27-37, 1997.

Wen, C.C., Marin, C., Dhir, V., Pagan-Marin, h., Gemery, J., Reid, S., La Salle, M.D., Salimpur, P., Adelstein, M., Shuiker, J., et. al. (1998). Atherosclerotic vascular disease of the iliohypogastric pudendal bed in females, IJIR 10: S64, 1998.

You're in a relationship. Something doesn't seem right, but you can't put your finger on it. Here's how to tell if your relationship is healthy or unhealthy for you.

Being in a HEALTHY RELATIONSHIP means ...	If you are in an UNHEALTHY RELATIONSHIP ...
Loving and taking care of yourself, before and while in a relationship.	You care for and focus on another person only and neglect yourself or you focus only on yourself and neglect the other person.
Respecting individuality, embracing differences, and allowing each person to "be themselves."	You feel pressure to change to meet the other person's standards, you are afraid to disagree, and your ideas or criticized. Or, you pressure the other person to meet your standards and criticize his/her ideas.
Doing things with friends and family and having activities independent of each other.	One of you has to justify what you do, where you go, and who you see.
Discussing things, allowing for differences of opinion, and compromising equally.	One of you makes all the decisions and controls everything without listening to the other's input.
Expressing and listening to each other's feelings, needs, and desires.	One of you feels unheard and is unable to communicate what you want.
Trusting and being honest with yourself and each other.	You lie to each other and find yourself making excuses for the other person.
Respecting each other's need for privacy.	You don't have any personal space and have to share everything with the other person.
Sharing sexual histories and sexual health status with a partner.	Your partner keeps his/her sexual history a secret or hides a sexually transmitted infection from you or you do not disclose your history to your partner.
Practicing safer sex methods.	You feel scared of asking your partner to use protection or s/he has refused your requests for safer sex. Or, you refuse to use safer sex methods after your partner has requested or you make your partner feel scared.
Respecting sexual boundaries and being able to say no to sex.	Your partner has forced you to have sex or you have had sex when you don't really want to. Or, you have forced or coerced your partner to have sex.
Resolving conflicts in a rational peaceful, and mutually agreed upon way.	One or both of you yells and hits, shoves or throws things at the other in an argument.
There is room for positive growth and you learn more about each other as you develop and mature.	You feel stifled, trapped, and stagnant. You are unable to escape the pressures of the relationship.

 

 

Symptoms of acute stress disorder are typically severe and disruptive, as acute stress disorder is a reaction to a traumatic event that impacts all areas of someone’s life (Traumatic Events and How to Cope).

Symptoms of acute stress disorder can be:

• Physiological; the sympathetic nervous system is activated, increasing heart rate and blood pressure as well as constricting blood vessels in order to prepare the person for fight or flight
• Behavioral changes
• Subjective; the person’s thoughts and emotions change

DSM-5 Categories of Acute Stress Disorder Symptoms

The DSM-5 delineates five categories of acute stress disorder symptoms. To receive a diagnosis of acute stress disorder following a traumatic event, someone must experience at least nine symptoms that fall into any of these five categories:

1. Intrusion symptoms
2. Negative mood
3. Dissociative symptoms
4. Avoidance symptoms
5. Arousal symptoms

Intrusion Symptoms of Acute Stress Disorder

Intrusion symptoms of acute stress disorder impose themselves into the person’s thoughts, emotions, and/or behavior. They’re involuntary; the person isn’t trying to ruminate over what happened. Intrusion symptoms of acute stress disorder can include:

• Repetitive, distressing memories of the traumatic event
• Recurrent, distressing dreams/nightmares related to the event
• Flashbacks; re-experiencing the trauma as if it were currently happening
• Intense physiological reactions in response to triggers that remind the person of the traumatic event

Symptoms of Acute Stress Disorder Involving Negative Mood

Negative mood involves:

• A constant inability to feel positive emotions such as happiness, joy, satisfaction, love, desire for intimacy, etc.
• An exclusive ability to feel negative emotions such as fear, sadness, despair, anger, guilt, shame, etc.

Dissociative Symptoms of Acute Stress Disorder

Dissociation is an involuntary defense mechanism that allows someone to remove him/herself from the intensity of acute stress disorder. Dissociative symptoms of acute stress disorder involve:

• Decreased awareness of surroundings
• An inability to remember important aspect(s) of the trauma (dissociative amnesia)
• Numbing
• Depersonalization; the sense that one isn’t real/an altered sense of self
• Derealization; the sense that surroundings aren’t real/an altered sense of the world

Avoidance Symptoms of Acute Stress Disorder

People experiencing acute distress disorder frequently avoid situations that remind them of the traumatic event or those in which they feel out of control. The avoidance includes:

• External reminders such as people, places, activities, objects, etc.
• Internal reminders such as memories, thoughts, feelings

Arousal Symptoms of Acute Stress Disorder

Arousal symptoms are a survival instinct, part of the fight-or-flight response. Arousal is supposed to be a protective mechanism, but in acute stress disorder, arousal is prolonged and problematic. Symptoms of acute stress disorder involving arousal include:

• Sleep problems
• Anxiety
• Irritability
• Anger/aggression
• Hypervigilance
• Difficulty concentrating
• Exaggerated startle response, jumpiness

Effects of Acute Stress Disorder

The effects of acute stress disorder can disrupt all areas of functioning. Among the effects of acute stress disorder are:

• Depression
• Thoughts of suicide
• Shame
• Self-blame, survivor guilt
• Distrust
• Withdrawal
• Absenteeism
• Refusal to talk about the event
• Difficulty self-soothing/turning to substance use
• Anxiety
• Fear of losing control or going crazy

Acute Stress Disorder Can Be A TRAP

Giarratano (2004) explains that many people feel trapped by their symptoms of acute stress disorder and uses a TRAP acronym to explain the symptoms and effects of acute stress disorder:

• Trance; people become numb, feeling like a robot
• Re-experience; intrusive memories and thoughts keep people stuck
• Avoidance; people begin to avoid life
• Physical tension; people remain in a state of heightened arousal

The symptoms of acute stress disorder can significantly reduce mental health and well-being. They are indeed a trap, but it’s possible to treat acute stress disorder and break free from this trap.

article references

For children with ADHD, peer relationships can present a significant challenge, but there are many things parents can do to improve the ADHD child's relationships.

Attention-Deficit Hyperactivity Disorder (ADHD) can have many effects on a child's development. It can make childhood friendships, or peer relationships, very difficult. These relationships contribute to children's immediate happiness and may be very important to their long-term development.

Research suggests that children with difficulty in their peer relationships, for example, being rejected by peers or not having close friends, suffer from self-esteem problems. In some cases, children with peer problems may also be at higher risk for anxiety, behavioral and mood disorders, substance abuse and delinquency as teenagers.

Parents of children with ADHD may be less likely to report that their child plays with groups of friends or is involved in after-school activities, and half as likely to report that their child has many good friends. Parents of children with ADHD may be more than twice as likely than other parents to report that their child is picked on at school or has trouble getting along with other children.

How does ADHD interfere with peer relationships?

Exactly how ADHD contributes to social problems is not fully understood. Several studies have found that children with predominantly inattentive ADHD may be perceived as shy or withdrawn by their peers. Research strongly indicates that aggressive behavior in children with symptoms of impulsivity/hyperactivity may play a significant role in peer rejection. In addition, other behavioral disorders often occur along with ADHD. Children with ADHD and other disorders appear to face greater impairments in their relationships with peers.

Having ADHD does not mean a person has to have poor peer relationships.

Not everyone with ADHD has difficulty getting along with others. For those who do, many things can be done to improve the person's relationships. The earlier a child's difficulties with peers are noticed, the more successful intervention may be. Although researchers have not provided definitive answers, some things parents might consider as they help their child build and strengthen peer relationships are:

• Recognize the importance of healthy peer relationships for children. These relationships can be just as important as grades to school success.
• Maintain on-going communication with people who play important roles in your child's life (such as teachers, school counselors, after-school activity leaders, health care providers, etc.). Keep up-dated on your child's social development in community and school settings.
• Involve your child in activities with his or her peers. Communicate with other parents, sports coaches and other involved adults about any progress or problems that may develop with your child.
• Peer programs can be helpful, particularly for older children and teenagers. Schools and communities often have such programs available. You may want to discuss the possibility of your child's participation with program directors and your child's care providers.

Source: National Center on Birth Defects and Developmental Disabilities, Sept. 2005

The modern era of male sexual dysfunction began in 1973 with the advent of the inflatable prosthetic devices by American Medical Systems. Female sexual dysfunction has basically been neglected because no therapy was available. With the advent of Viagra by Pfizer Pharmaceuticals, effective therapy for some forms of female sexual dysfunction may become available to the general public.

Female sexual dysfunction can be classified into five basic areas including:

1. Desire problems
2. Arousal difficulties
3. Lubrication factors
4. Pelvic congestion
5. Orgasmic difficulties

For males, desire problems are minimal and usually related to hormonal difficulties. For females, desire problems occur in more than 33 percent of dysfunction cases. This is probably related to the more complex psychological aspects of female sexuality. On the other hand, many of these patients can be helped. In males, desire problems make up only five percent of all sexual dysfunction. Arousal, lubrication, and pelvic congestion issues together probably represent about half of all female sexual problems and, fortunately, is the area in which pharmacology in the near future appears to offer the greatest hope.

Orgasmic problems make up the significant remainder (17 percent) and are the hardest overall to treat. However, improvement in desire, arousal, pelvic congestion, and lubrication in some cases may lead to satisfactory orgasmic responses.

The issue of pelvic, genital and vaginal discomfort during sexual activity which is extremely complex and can be related to multiple factors including bowel, bladder and local pathology. So what should women do?

A woman--regardless of age -- with a sexual problem should see a qualified doctor and have a good medical and sexual history taken, a general physical exam, with a good genital and pelvic examination, followed by basic blood studies, including CBC and chemical profile. Specific pathology or causes for pelvic or genital pain, or any other pelvic or general pathology, should be treated. But in the end, most women will have function problems --desire, arousal, lubrication, pelvic congestion and orgasm.

Women need to know that some help is here now and that other modalities that are either already accepted or are in the development phase.

APOMORPHINE: An old medication originally used as an emetic. It has a central enhancing effect working on the paraventricular nuclei of the brain stem and allowing sexual stimulation to increase central sexual function. This drug appears in women not to improve sexual desire, but will take stimuli that normally is not effective in producing improved sexual function to more normal sexual capabilities. Research is being done now on this drug and use on women.

Since sexual desire problems represent one-third of all sexual problems in females this drug may play a role in women who have diminished sexual desire since it potentiates central sexual stimulation. Side effects include nausea and vomiting, hypotension, and syncope. It appears that the 2 and 4 mg dosage sublingually (under the tongue) will be available and its effects should be within 10 to 15 minutes of sublingual absorption. This drug will be able to be used in patients who are taking nitrates on a regular basis for angina. This is also big news to men who take nitrates and are warned NOT to take Viagra.

TESTOSTERONE: Testosterone is the most commonly used drug for the treatment of sexual dysfunction in women. It appears best in those women in which desire is diminished. Extremely low doses, one-tenth the dose that males take is all that is necessary for its positive sexual effects on women. Twenty mg subcutaneously (under the skin) every three weeks is a fairly standard dose. Creams, patches, and combinations with estrogen and progestational agents are being developed. Its major side effects include masculinization, but when used properly rarely occurs. The oral forms of testosterone should never be used on a chronic basis due to its high incidence of serious liver toxicity.

VIAGRA (sildenafil citrate): Viagra has revolutionized male sexual dysfunction with approximately 75 percent of men responding. It works by inhibiting the phosphodiesterase inhibiting enzyme that is specifically found in the male and female pelvic area (type V phosphodiesterase inhibitor). By inhibiting this enzyme cyclic GMP is stimulated and with it associated dilation of the pelvic blood vessels, increased blood flow, and pelvic congestion occurs.

Improved vaginal engorgement and lubrication are the major byproducts of this medication. Side effects have been minimal with facial flushing, headaches, stomach upset, and a brightened vision associated with a green-blue halo. This drug should never be taken with nitrates since serious life-threatening complications may occur. Nitroclycerine and nitrate-containing drugs should never be given with 24 hours of Viagra. The drug is absorbed best on an empty stomach and one should wait for at least one hour before sexual stimulation to allow maximal effect. A window of 1 to 4 hours after taking the drug appears to be optimal, however, it is not unheard of for this drug to have sexual potentiating effects for as long as 12 to 14 hours.

VASOMAX: Vasomax is the next male sexual drug to probably be introduced in the United States. It is a rapid-released form of phentolamine, a general alpha I blocking agent that increases blood flow to the organs of the body including the pelvic organs such as the vagina. It will work similarly to Viagra in the sense of improving vaginal engorgement, lubrication, and probably arousal. It can be taken in patients who are using nitroclycerine or nitrate medications for angina. Its major side effects include a transient drop in blood pressure associated with syncope, nausea, and vomiting.

Female sexual dysfunction is beginning to be treated by use of medications that are being developed for male sexual dysfunctions. Apomorphine for male sexual dysfunction will have a role in female sexual dysfunction as well. Viagra and Vasomax will have similar female sexual dysfunction treatment use. Expect newer and more exciting drugs for female sexual dysfunction to grow from the research in male sexual difficulties.

Acute stress disorder and acute stress reaction can develop in anyone in response to direct exposure to a traumatic event. A traumatic event is an event so threatening to the core of someone’s sense of self and the world that it overwhelms his/her ability to cope.

When humans face traumatic events such as severe accidents, threatened or actual violence, natural or human-made disasters, or exposure to war, automatic reactions are survival-based. Along with emotional and physical responses to trauma, people seek to process and understand events and figure out how they fit into their life picture.

Sometimes, however, the trauma responses aren’t adaptive. Rather than moving forward, the person remains stuck in the trauma. When this happens, a person experiences an acute stress reaction or acute stress disorder.

Criteria for Acute Stress Disorder

Among the defining criteria for Acute Stress Disorder established in the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5), three are prominent criteria:

1. Exposure to a traumatic event/stressor that involves actual or threatened death, serious injury, or sexual violation and causes specific symptoms
2. The symptoms must begin within three days of the event (a diagnosis can’t be given until day three) and must last more than three days but subside within one month
3. Symptoms must cause distress or impairment.

Exposure to a traumatic event or extreme stressor means that the person was present at the time of the trauma and either directly experienced harm or witnessed firsthand (as opposed to on the news or social media) the trauma occurring to others.

A person may also be diagnosed with acute stress disorder if he/she learns that a family member or close friend experienced a violent or accidental trauma. Further, acute stress disorder can be diagnosed in people who experience repeated exposure to details of traumatic events, again, in person rather than through media.

What is Acute Stress Reaction?

Acute stress reaction isn’t a diagnosable disorder but is a short-term response to a traumatic event. Acute stress reaction begins immediately at the time of the event and lasts up to two- to three days.

Anxiety and depression are widespread in acute stress reactions. Additionally, acute stress reaction can include withdrawal, narrowing of attention to the event and outcomes of it, disorientation, despair, hopelessness, grief, anger, and/or heightened arousal.

Who is Susceptible to Acute Stress Disorder?

Anyone can have an acute stress reaction or develop acute stress disorder after a traumatic event. That said, there are certain factors that increase someone’s risk. These include:

• Severity and type of trauma (traumatic events that are human-induced, violent, and/or intentional are more likely to lead to a trauma disorder than are natural disasters or accidents)
• Inadequate support systems
• Past trauma
• Pre-existing mental illness
• Substance use/abuse
• Degree of functioning prior to the trauma
• Recent stressful life experiences/changes
• Meaning one assigns to the traumatic event
• Belief that more harm will continue
• Negative effect like anxiety, depression, anger, guilt, hopelessness, etc.
• Unhelpful coping skills
• High levels of pain
• Being female

The prevalence of acute stress disorder hasn’t been determined with certainty. The percentage of people who develop acute stress disorder after a traumatic event varies according to the event and even these percentages don’t have a high degree of reliability due to the current lack of a uniform method of gathering data. Very general statistics indicate that for human-induced violent traumas, over 20 percent of people develop acute stress disorder. Acute stress disorder isn’t rare.

Acute stress disorder can be all-consuming, negatively impacting someone’s entire life. Acute stress disorder isn’t a weakness; it’s a reaction to external trauma. Acute stress disorder is treatable, and people can live fully again.

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