Presentation on theme: "Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders"— Presentation transcript:
1 Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders Chapter ThirteenSexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders
2 What is “Normal” Sexual Behavior? Three categories discussed:Sexual dysfunctions:Problems in the normal sexual response cycle that affects sexual interest, arousal, and responseGender dysphoria:Incongruity or conflict between one’s anatomical sex and one’s psychological feeling of being male or femaleParaphilic disorders:Sexual urges and fantasies about situations, objects, or people that prove problematicIn a national survey of 18- to 44-year-olds ( Mosher, Chandra, & Jones, 2005), 90 percent of men identified themselves as heterosexual, 2.3 percent homosexual, 1.8 percent bisexual, and 3.9 percent something else; 1.8 percent did not respond. For women the responses were nearly identical: 90 percent heterosexual, 1.3 percent homosexual, 2.8 percent bisexual, and 3.8 percent something else; 1.8 percent did not answer.
3 What is “Normal” Sexual Behavior? (cont’d.) Difficulty distinguishing between abnormal behavior and harmless variations in preferences and tastesDefinitions vary widely and are influenced by both moral and legal judgmentsDifficult when comparing Western and non-Western cultures or different time periods
4 The Study of Human Sexuality Freud made the discussion of sexual topics more acceptable by incorporating sex (libido) as an important part of psychoanalytic theoryContemporary understanding of human sexual physiology, practices, and customs:Research of Alfred Kinsey, William Masters and Virginia Johnson, and The Janus ReportFindings of the National Survey of Sexual Health and Behavior and work of contemporary sex researchers
5 The Sexual Response Cycle Four stages:Appetitive phase:Characterized by person’s interest in sexual activityArousal phase:May follow or precede the appetitive phaseIs heightened and intensified when specific and direct sexual stimulation occurs
6 Sexual Interest/Arousal Disorders (cont’d.) in DSM-5:Sexual aversion disorder is removed.Making distinct, separate, and parallel diagnoses for sexual interest/arousal disorders in women and sexual interest/arousal disorders in menDisorders can be lifelong, acquired, generalized, or situational
7 The Sexual Response Cycle? (cont’d.) Four stages:Orgasm phase:Characterized by involuntary muscular contractions throughout the body and eventual release of sexual tensionFemales are capable of multiple orgasmsResolution phase:Characterized by relaxation of the body after orgasmHeart rate, blood pressure, and respiration return to normal
8 The Sexual Response Cycle? (cont’d.) Figure 13-1 Human Sexual Response Cycle The studies of Masters and Johnson reveal similar normal sexual response cycles for men and women. Note that women may experience more than one orgasm. Sexual disorders may occur at any of the phases, but seldom at the resolution phase.
9 Sexual DysfunctionsA disruption of any part of the normal sexual response cycle that affects sexual desire, arousal, and responseTo be diagnosed, dysfunction must be recurrent and persistentDSM-IV-TR also requires consideration of:Frequency, chronicity, subjective distress, and effect on other areas of functioning
10 Sexual Dysfunctions (cont’d.) 40–45 percent of adult women and 20–30 percent of adult men have at least one sexual dysfunction ( R. W. Lewis et al., 2004).
11 Sexual Interest/Arousal Disorders Related to appetitive and arousal phasesCharacterized by a lack of sexual interest or arousal over prolonged period of timeDSM-V includes:Hypoactive sexual desire disorderSexual aversion disorderFemale sexual arousal disorderSome clinicians estimate that 40–50 percent of all sexual dysfunctions involve deficits in interest; these are now the most common complaint of couples seeking sex therapy.
12 Sexual Interest/Arousal Disorders (cont’d.) Erectile disorder:Inability to attain or maintain an erection sufficient for sexual intercourse or psychological arousal during sexual activityDistinguishing between biological and psychological causes has been difficultPrimary erectile dysfunction: man has never been able to successfully have intercourseSecondary erectile dysfunction: man has had at least one successful instance of intercourse70 percent of erectile dysfunctions are caused by some form of vascular insufficiency, such as diabetes, atherosclerosis, or traumatic groin injury, or by other physiological factors.
13 Sexual Interest/Arousal Disorders (cont’d.) Hypersexual disorderFindings support existence of disorderCraving for constant sex at the expense of relationships, work, productivity, and daily activities (DSM-5)Causes personal psychological distress and other consequences
14 Orgasmic Disorders Female orgasmic disorder: Sexual dysfunction in which the woman experiences persistent delay or inability to achieve orgasm with stimulation that is adequate in focus, intensity, and duration after entering the excitement phasePrimary:Orgasm has never been experiencedSecondary:Orgasm has been experienced
15 Orgasmic Disorders (cont’d.) Delayed ejaculation:Persistent delay or inability to achieve an orgasm after the excitement phase has been reached and sexual activity has been adequate in focus, intensity, and durationUsually restricted to an inability to ejaculate within the vaginaIn DSM V, delayed ejaculation is the new name for male orgasmic disorder.
16 Orgasmic Disorders (cont’d.) Early ejaculation:Ejaculation with minimal sexual stimulation before, during, and shortly after penetrationGenito-pelvic pain/penetration disorder:Involves physical pain or discomfort associated with intercourse or penetrationDyspareuniaRecurrent or persistent pain in the genitalsVaginismusInvoluntary spasm of the outer third of the vaginal wallDSM V does include female sexual interest/arousal disorder and male hypoactive sexual desire disorder as well as Genito-Pelvic Pain/Penetration Disorder (which describes symptoms for women only). Vaginismus is considered very rare. Differentiating between dyspareunia and vaginismus is difficult and unreliable.
17 Etiology of Sexual Dysfunctions There is perhaps no other group of mental disorders in which the interaction of biological, psychological, social, and sociocultural dimensions is as clearly demonstrated as in sexual dysfunctions.Figure 13-4 Multipath Model of Sexual Dysfunctions The dimensions interact with one another and combine in different ways to result in a specific sexual dysfunction.
18 Biological DimensionLevels of testosterone (low) or estrogens (high) linked to lower sexual interest in men and women, and erectile difficulties in menMedications used to treat medical conditions affect sex driveSome believe alcohol is leading cause of disordersIllnesses and other physiological factorsAmount of blood flow into genital areaDrugs that suppress testosterone appear to decrease sexual desire in men. Many people with sexual dysfunctions have normal testosterone levels ( Hyde, 2005).Some researchers believe that alcohol abuse is the leading cause of erectile disorders, as well as of early ejaculation.
19 Psychological Dimension Traditional psychoanalysts focus on the role of unconscious conflictsCognitive theorists focus on performance anxiety and spectator roleRole of early psychosexual experiencesSituational or coital anxiety for womenRe: early psychosexual experiences: Men with early ejaculation, for example, have been found to have less sexual intercourse than their counterparts without early ejaculation ( Rowland & McMahon, 2008). It is possible that fewer sexual experiences predispose them to higher excitement and arousal.Re: situational or coital factors for women, fear of pregnancy, of STDs, performance anxiety,
20 Social Dimension Social upbringing and current relationships Being raised in strict religious environmentTraumatic sexual experiencesRelationship issues often forefront of sexual disorders among and between men and womenU.S. Americans have the most sexPeople in Japan (36 times per year), Hong Kong (63 times per year), Taiwan (65 times per year), and China (72 times per year) have the least sex.
21 Sociocultural Dimension Sexual behavior and functioning influenced by gender, age, cultural scripts, education level, country of originFor example, women:Are capable of multiple orgasmsEntertain different sexual fantasiesHave a broader arousal pattern to sexual stimuliAre more attuned to relationships in sex encounterTake longer than men to become aroused
22 Sociocultural Dimension (cont’d.) Cultural scripts can have a major impact on sexual functioningCultural scripts are the social and cultural beliefs and expectations that guide our behaviors regarding sexVary from explicit to implicitSexual orientation:No physiological differences in sexual arousal and response between homosexuals and heterosexualsSexual issues may differ dramaticallyAlthough there are no physiological differences in sexual arousal and response between lesbians and gay men, lesbians and gay men must also deal with societal or internalized homophobia - which often inhibits open expression of their affection toward one another ( M. S. Schneider, Brown, & Glassgold, 2002).These broader contextual issues may create diminished sexual interest or desire, sexual aversion, and negative feelings toward sexual activity.
23 Treatment of Sexual Dysfunctions Biological interventions:Hormone replacementSpecial medications or mechanical meansVacuum pumps, suppositories, and penile implantsFor ED, injection of substances into penisOral medications (Viagra, Levitra, Cialis) are alternative to injection therapy
24 Treatment of Sexual Dysfunctions (cont’d.) Psychological treatment approaches:Include following components:EducationReplace myths and misconceptions with factsAnxiety reductionDesensitization or graded approachesStructured behavioral exercisesGraded tasks that gradually increase amount of sexual interactionCommunication trainingTeaching appropriate ways of communicating sexual wishes
25 Treatment of Sexual Dysfunctions (cont’d.) Psychological treatment approaches:Specific nonmedical treatments:Female orgasmic dysfunction:Masturbation most effective for womenEarly ejaculation:Petting and stopping“Squeeze Technique”Vaginismus:Training vaginal musclesApproximately 89 percent of men with penile implants and 70 percent of their partners expressed satisfaction with the implants and most said that they would choose the treatment again.Viagra does not provide physiological help that will enable normally functioning men to improve their sexual functioning, nor does it lead to a stiffer erection. These drugs may aid sexual arousal and performance by stimulating men's expectations and fantasies; this psychological boost may then lead to subjective feelings of enhanced pleasure.
26 Aging, Sexual Activity, and Sexual Dysfunctions Aging is one of most powerful predictors of changing sexual functioning2007 findings of over 3, year oldsSexual activity declines with ageWomen far more likely to report less sexual activity at all agesAmong sexually active men and women, 50% report at least one bothersome sex problemAging has been found to be one of the most powerful predictors of changing sexual functioning even when the effects of illness, medication, and psychopathology are controlled for.
27 Aging, Sexual Activity, and Sexual Dysfunctions (cont’d.) More findings:Most frequent problems in women:Low sexual interest/desire, problems with lubrication, inability to climaxMost frequent problems in men:Erectile difficulties
28 Aging, Sexual Activity, and Sexual Dysfunctions (cont’d.) Effects of aging on sexuality:Estrogen levels drop in womenProstate problems increase in menBoth sexes at increased risk for illnesses that affect sexual performance and interestMedical procedures help minimize effects of organically-based problems
29 Aging, Sexual Activity, and Sexual Dysfunctions (cont’d.) The Janus Report (1993):Sexual activity of people ages 65 and older declined little from that of 30 and 40-year oldsAbility to reach orgasm and have sex diminished littleUnchanged desire to continue relatively active sex life
30 Gender DysphoriaPreviously called gender identity disorder (GID) or transsexualism:Conflict between a person’s anatomical sex and his/her gender identity, or self-identification as male or femaleNot the same as sexual orientationA transsexual can be heterosexual, homosexual, bisexual, or asexualIndividuals experience strong and persistent gender incongruence from young ageGender dysphoria may or may not be manifested in significant impairment in social, occupational, or other important areas of functioning. People with this disorder hold a lifelong conviction that nature has placed them in a body of the wrong sex. This feeling produces a preoccupation with eliminating the physical and behavioral sexual characteristics associated with the body's sex and acquiring those of the person's experienced gender instead.People with gender dysphoria tend to exhibit gender-role incongruence at an early age and to report conflicted gender-role feelings in childhood, some as early as two years old.Girls with gender dysphoria may insist that they have a penis or will grow one and may exhibit an avid interest in rough-and-tumble play.
31 Etiology of Gender Dysphoria Etiology is unclearDisorder is rare; research has focused on other sexual disordersProbably an interaction of multiple variablesBiological factors strongly implicated
32 Etiology of Gender Dysphoria (cont’d.) Biological influences:Neurohormonal factors, genetics, and possible brain differences may be involvedRole of testosterone and hypothalamusMust be viewed with cautionPsychological and social influences must be viewed with cautionChildhood experiencesRe: neurohormonal influences: The presence or absence of testosterone early in life appears to influence the organization of brain centers that govern sexual behavior.Gender dysphoria appears to be more common in males than in females and may appear in both adults and childrenGenetics and differences in areas of the hypothalamus have also been found in some studies to correlate with the development of gender dysphoriaThese studies suggest that gender dysphoria may run in families and that there are differences in the size of brain clusters in regions of the hypothalamus between men with and men without gender dysphoria
33 Treatment of Gender Dysphoria Psychotherapy and hormone therapySex reassignment surgery1 in 30,000 adult males and 1 in 100,000 adult femalesStudies show positive outcomesPsychotherapy is unlikely to be effective in changing gender identity, but may help individuals deal with the psychological effects. Labeling gender dysphoria as a disorder stirs up major conflicts.until 2004—the International Olympic Committee denied transgender people the right to compete (unless they had undergone sex reassignment and had at least 2 years of postoperative hormone-replacement therapy)Discrimination in health care, employment, and education are often experienced due to prejudice and discrimination. Transgender people are often portrayed as less than human, an anomaly, and referred to as “shims” or “shemales.”many who allegedly have gender dysphoria do not regard their feelings and desires as abnormal ( Granderson, 2010; Winters, 2007).
34 Paraphilic Disorders Sexual disorders lasting at least six months During which the person has either acted on, or is severely distressed by, recurrent urges or fantasies involving:Nonhuman objectsNonconsenting individualsReal or simulated suffering or humiliationIn DSM V, paraphilias are not disorders in and of themselves. In order for a paraphilia to meet the criteria for a paraphilic disorder, the paraphilia must cause distress or impairment or harm, risk of harm or distress for others.
35 Paraphilic Disorders Involving Nonhuman Objects Fetishistic disorder:Extremely strong sexual attraction and fantasies involving inanimate objects, such as female undergarmentsCauses significant distress to self or othersMost common in menRare among women
36 Paraphilic Disorders Involving Nonhuman Objects (cont’d.) Transvestic disorder:Intense sexual arousal obtained through cross-dressing (wearing clothes appropriate to the opposite gender)Do not confuse with gender dysphoriaClinically significant distress or impairment in important areas of functioningMuch higher prevalence among menA diagnosis of fetishistic disorder is not made if the inanimate object is an article of clothing used only in cross-dressing. In such cases, the appropriate diagnosis would be transvestic disorder —intense sexual arousal obtained through cross-dressing (wearing clothes appropriate to a different gender).Although some transgender people and some lesbians and gay men cross-dress, most people who cross-dress are exclusively heterosexual and married.
37 Paraphilic Disorders Involving Nonconsenting Persons Exhibitionistic disorder:Urges, acts, or fantasies of exposing one’s genitals to strangersIndividuals who have it are most often male, and their targets female.Often intent to shockMain goal is sexual arousalVoyeuristic disorder:Urges, acts, or fantasies involving observation of an unsuspecting person disrobing or engaging in sexual activity; arrest is predictable.Most people with voyeuristic disorder are not interested in looking at their spouses or partners; an overwhelming number of voyeurism acts involve strangers.
38 Paraphilic Disorders Involving Nonconsenting Persons (cont’d.) Frotteuristic disorder:Recurrent/intense sexual urges, acts, or fantasies of touching or rubbing against a nonconsenting person
39 Paraphilic Disorders Involving Nonconsenting Persons (cont’d.) Pedophilic disorder:Adult obtains erotic gratification through urges, acts, or fantasies involving sexual contact with a prepubescent/early pubescent child20-30% of women report childhood sexual encounters with a manMost likely a relative, friend, or casual acquaintancePhysical and psychological symptoms of victims:Urinary tract infections, poor appetite, headachesNightmares, acting out, difficulty sleepingMusician Jerry Lee Lewis married a 13-year-old girl in the 1950s,According to the DSM-IVTR, a person must be at least 16 years of age to be diagnosed with this disorder (although the DSM-5 Work Groups recommend 18 years) and at least 5 years older than the victimPeople with this disorder may victimize children within and outside of their families.
40 Paraphilic Disorders Involving Nonconsenting Persons (cont’d.) Incest:Considered a form of pedophilic disorderCan also be sexual relations between people too closely related to marry legallyNearly universally taboo in societyVictims often feel guilty and powerlessHigh rates of drug abuseSexual dysfunctionPsychiatric problemsThe cases of incest most frequently reported to law enforcement agencies are those between a father and daughter or stepdaughter. However, the most common incestuous relationship is brother–sister incest, not parent–child incest. Mother–son incest seems to be rare. Sexual activities between siblings are relatively frequent.Father–daughter incest generally begins when the daughter is between 6 and 11 years old
41 Paraphilic Disorders Involving Pain or Humiliation Sexual sadism disorder:Sexually arousing urges, fantasies, or acts are associated with inflicting physical or psychological suffering on othersSexual masochism disorder:Sexual urges, fantasies, or acts are associated with being humiliated, bound, or made to sufferFor diagnosis:Person must have acted on urges and been distressed by themFor some people who are sadistic or masochistic, coitus becomes unnecessary; pain or humiliation alone is sufficient to produce sexual pleasure.
42 Paraphilic Disorders Involving Pain or Humiliation (cont’d.) Most sadomasochists engage in both submissive and dominant rolesMany engage in spanking, whipping, & bondageMost do not seek harm or injury, but they find sensation of helplessness appealingS&M often involves mutual consentConsidered deviant when pain, either inflicted or received, is necessary for sexual arousalOnly 16 percent are exclusively dominant or submissive. Activities are often carefully scripted.
43 Etiology and Treatment of Paraphilic Disorders Biological factors:Conflicting findings regarding genetic, neurohormonal, and brain anomaly explanationsMen may be biologically predisposed to pedophilic disorderDeficits in brain activation and less white matter
44 Etiology and Treatment of Paraphilic Disorders (cont’d.) Psychological factors:Psychodynamic theories:Unconscious childhood conflictsCastration anxietyTreatment:Help patient understand relationship between deviation and unconscious conflict
45 Etiology and Treatment of Paraphilic Disorders (cont’d.) Social factors:Learning theory stresses early conditioning experiencesTreatment:Weakening or eliminating sexually inappropriate behaviors through processes such as extinction or aversive conditioningAcquiring or strengthening sexually appropriate behaviorsDeveloping appropriate social skills
46 RapeSexual aggression that involves sexual activity performed against a person’s will through the use of force, argument, pressure, alcohol or drugs, or authorityNot considered a DSM disorderStatutory rape:Sexual intercourse with a child younger than age of consent
47 Rape (cont’d.) 1.3 rapes happen every minute in U.S. 90% of rapists attack persons of same raceDate rape, or acquaintance rape:Majority of all rapes8-25% of female college students report having “unwanted sexual intercourse”Many reluctant to reportonly about 16 percent of reported cases resulted in a conviction for rape, with 4 percent of those producing convictions for lesser offenses.most rapists are deliberate and plan their attacks
48 Rape (cont’d.) Characteristics of rapists: Create situations in which sexual encounters may occurInterpret friendliness as provocation and protest as insincerityManipulate women into sexual encounters with alcohol (70%) or “date rape drugs”Attribute failed attempts at sexual encounters to perceived negative features of the woman
49 Rape (cont’d.) More characteristics of rapists: Come from environments of parental neglect or physical or sexual abuseInitiate coitus earlier than men who ware not sexually aggressiveHave more sexual partners than non-sexually aggressive men
50 Effects of Rape Rape trauma syndrome: Two phases: Includes psychological distress, phobic reactions, and sexual dysfunction (consistent with PTSD)Two phases:Acute phase: DisorganizationFeelings of self-blame, fear, and depressionLong-term phase: ReorganizationLingering fears/phobic reactions, and difficulty resuming sexual activity/enjoymentIn 1989, while jogging through New York's Central Park, Trisha Meili was raped, sodomized, and beaten so savagely that she lost 75 percent of her blood before she was found. At the hospital, doctors believed she would not live, but Meili fought valiantly for her life and survived the ordeal. She became known as the “Central Park Jogger,” and her case generated a national debate about rape and violence in society. After years of recovery, she finally wrote a book—I Am the Central Park Jogger: A Story of Hope and Possibility ( Meili, 2003).
51 Etiology of Rape 1977 study: Power rapist: 55% of rapists Compensate for feelings of personal/sexual inadequacy by trying to intimidate victimsAnger rapist: 40% of rapistsAngry at women in generalSadistic rapist: 5% of rapistsDerives satisfaction from inflicting painMay torture or mutilate victims
52 Etiology of Rape (cont’d.) Rape has more to do with power, aggression, and violence than sexRecent findings suggest rape is partially sexually motivated:Most rape victims are in their teens or 20sMost rapist name sexual motivation as primary reason for actionsMany rapists seem to have multiple paraphilias
53 Etiology of Rape (cont’d.) Media portrayals of violent sex reflect/affect attitudes and thoughts and influence patterns of sexual arousal“Cultural spillover” theory:Rape is high in environments that encourage violence
54 Treatment for RapistsMany believe sex offenders are not good candidates for treatment or rehabilitationHigh recidivism ratesMost frequent response is imprisonment with little or no treatment
55 Treatment for Rapists (cont’d.) Behavioral treatment for sexual aggressorsAssess sexual interests through self-report and measuring erectile responses to different stimuliReduce deviant interests (aversion therapy)Orgasmic reconditioning/masturbation retraining to appropriate stimuliSocial skills trainingAssessment after treatmen
56 Treatment for Rapists (cont’d.) Surgical castrationUsed in EuropeLow relapse ratesChemical therapyUsually use of Depo-ProveraReduces self-reports of sexual urges in child molesters (i.e., psychological desire)Does not reduce genital arousal (erectile capabilities)