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Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders

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1 Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders
Chapter Thirteen Sexual 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 response Gender dysphoria: Incongruity or conflict between one’s anatomical sex and one’s psychological feeling of being male or female Paraphilic disorders: Sexual urges and fantasies about situations, objects, or people that prove problematic In 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 tastes Definitions vary widely and are influenced by both moral and legal judgments Difficult 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 theory Contemporary understanding of human sexual physiology, practices, and customs: Research of Alfred Kinsey, William Masters and Virginia Johnson, and The Janus Report Findings 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 activity Arousal phase: May follow or precede the appetitive phase Is 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 men Disorders 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 tension Females are capable of multiple orgasms Resolution phase: Characterized by relaxation of the body after orgasm Heart 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 Dysfunctions A disruption of any part of the normal sexual response cycle that affects sexual desire, arousal, and response To be diagnosed, dysfunction must be recurrent and persistent DSM-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 phases Characterized by a lack of sexual interest or arousal over prolonged period of time DSM-V includes: Hypoactive sexual desire disorder Sexual aversion disorder Female sexual arousal disorder Some 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 activity Distinguishing between biological and psychological causes has been difficult Primary erectile dysfunction: man has never been able to successfully have intercourse Secondary erectile dysfunction: man has had at least one successful instance of intercourse 70 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 disorder Findings support existence of disorder Craving 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 phase Primary: Orgasm has never been experienced Secondary: 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 duration Usually restricted to an inability to ejaculate within the vagina In 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 penetration Genito-pelvic pain/penetration disorder: Involves physical pain or discomfort associated with intercourse or penetration Dyspareunia Recurrent or persistent pain in the genitals Vaginismus Involuntary spasm of the outer third of the vaginal wall DSM 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 Dimension Levels of testosterone (low) or estrogens (high) linked to lower sexual interest in men and women, and erectile difficulties in men Medications used to treat medical conditions affect sex drive Some believe alcohol is leading cause of disorders Illnesses and other physiological factors Amount of blood flow into genital area Drugs 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 conflicts Cognitive theorists focus on performance anxiety and spectator role Role of early psychosexual experiences Situational or coital anxiety for women Re: 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 environment Traumatic sexual experiences Relationship issues often forefront of sexual disorders among and between men and women U.S. Americans have the most sex People 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 origin For example, women: Are capable of multiple orgasms Entertain different sexual fantasies Have a broader arousal pattern to sexual stimuli Are more attuned to relationships in sex encounter Take longer than men to become aroused

22 Sociocultural Dimension (cont’d.)
Cultural scripts can have a major impact on sexual functioning Cultural scripts are the social and cultural beliefs and expectations that guide our behaviors regarding sex Vary from explicit to implicit Sexual orientation: No physiological differences in sexual arousal and response between homosexuals and heterosexuals Sexual issues may differ dramatically Although 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 replacement Special medications or mechanical means Vacuum pumps, suppositories, and penile implants For ED, injection of substances into penis Oral medications (Viagra, Levitra, Cialis) are alternative to injection therapy

24 Treatment of Sexual Dysfunctions (cont’d.)
Psychological treatment approaches: Include following components: Education Replace myths and misconceptions with facts Anxiety reduction Desensitization or graded approaches Structured behavioral exercises Graded tasks that gradually increase amount of sexual interaction Communication training Teaching 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 women Early ejaculation: Petting and stopping “Squeeze Technique” Vaginismus: Training vaginal muscles Approximately 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 functioning 2007 findings of over 3, year olds Sexual activity declines with age Women far more likely to report less sexual activity at all ages Among sexually active men and women, 50% report at least one bothersome sex problem Aging 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 climax Most frequent problems in men: Erectile difficulties

28 Aging, Sexual Activity, and Sexual Dysfunctions (cont’d.)
Effects of aging on sexuality: Estrogen levels drop in women Prostate problems increase in men Both sexes at increased risk for illnesses that affect sexual performance and interest Medical 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 olds Ability to reach orgasm and have sex diminished little Unchanged desire to continue relatively active sex life

30 Gender Dysphoria Previously 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 female Not the same as sexual orientation A transsexual can be heterosexual, homosexual, bisexual, or asexual Individuals experience strong and persistent gender incongruence from young age Gender 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 unclear Disorder is rare; research has focused on other sexual disorders Probably an interaction of multiple variables Biological factors strongly implicated

32 Etiology of Gender Dysphoria (cont’d.)
Biological influences: Neurohormonal factors, genetics, and possible brain differences may be involved Role of testosterone and hypothalamus Must be viewed with caution Psychological and social influences must be viewed with caution Childhood experiences Re: 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 children Genetics and differences in areas of the hypothalamus have also been found in some studies to correlate with the development of gender dysphoria These 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 therapy Sex reassignment surgery 1 in 30,000 adult males and 1 in 100,000 adult females Studies show positive outcomes Psychotherapy 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 objects Nonconsenting individuals Real or simulated suffering or humiliation In 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 undergarments Causes significant distress to self or others Most common in men Rare 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 dysphoria Clinically significant distress or impairment in important areas of functioning Much higher prevalence among men A 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 strangers Individuals who have it are most often male, and their targets female. Often intent to shock Main goal is sexual arousal Voyeuristic 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 child 20-30% of women report childhood sexual encounters with a man Most likely a relative, friend, or casual acquaintance Physical and psychological symptoms of victims: Urinary tract infections, poor appetite, headaches Nightmares, acting out, difficulty sleeping Musician 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 victim People 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 disorder Can also be sexual relations between people too closely related to marry legally Nearly universally taboo in society Victims often feel guilty and powerless High rates of drug abuse Sexual dysfunction Psychiatric problems The 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 others Sexual masochism disorder: Sexual urges, fantasies, or acts are associated with being humiliated, bound, or made to suffer For diagnosis: Person must have acted on urges and been distressed by them For 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 roles Many engage in spanking, whipping, & bondage Most do not seek harm or injury, but they find sensation of helplessness appealing S&M often involves mutual consent Considered deviant when pain, either inflicted or received, is necessary for sexual arousal Only 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 explanations Men may be biologically predisposed to pedophilic disorder Deficits in brain activation and less white matter

44 Etiology and Treatment of Paraphilic Disorders (cont’d.)
Psychological factors: Psychodynamic theories: Unconscious childhood conflicts Castration anxiety Treatment: 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 experiences Treatment: Weakening or eliminating sexually inappropriate behaviors through processes such as extinction or aversive conditioning Acquiring or strengthening sexually appropriate behaviors Developing appropriate social skills

46 Rape Sexual aggression that involves sexual activity performed against a person’s will through the use of force, argument, pressure, alcohol or drugs, or authority Not considered a DSM disorder Statutory 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 race Date rape, or acquaintance rape: Majority of all rapes 8-25% of female college students report having “unwanted sexual intercourse” Many reluctant to report only 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 occur Interpret friendliness as provocation and protest as insincerity Manipulate 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 abuse Initiate coitus earlier than men who ware not sexually aggressive Have 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: Disorganization Feelings of self-blame, fear, and depression Long-term phase: Reorganization Lingering fears/phobic reactions, and difficulty resuming sexual activity/enjoyment In 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 victims Anger rapist: 40% of rapists Angry at women in general Sadistic rapist: 5% of rapists Derives satisfaction from inflicting pain May torture or mutilate victims

52 Etiology of Rape (cont’d.)
Rape has more to do with power, aggression, and violence than sex Recent findings suggest rape is partially sexually motivated: Most rape victims are in their teens or 20s Most rapist name sexual motivation as primary reason for actions Many 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 Rapists Many believe sex offenders are not good candidates for treatment or rehabilitation High recidivism rates Most frequent response is imprisonment with little or no treatment

55 Treatment for Rapists (cont’d.)
Behavioral treatment for sexual aggressors Assess sexual interests through self-report and measuring erectile responses to different stimuli Reduce deviant interests (aversion therapy) Orgasmic reconditioning/masturbation retraining to appropriate stimuli Social skills training Assessment after treatmen

56 Treatment for Rapists (cont’d.)
Surgical castration Used in Europe Low relapse rates Chemical therapy Usually use of Depo-Provera Reduces self-reports of sexual urges in child molesters (i.e., psychological desire) Does not reduce genital arousal (erectile capabilities)

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