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Chapter Thirteen Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders.

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Presentation on theme: "Chapter Thirteen Sexual Dysfunction, Gender Dysphoria, and Paraphilic Disorders."— Presentation transcript:

1 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

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.)

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

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

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

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

17 Etiology of 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

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

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

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

26 Aging, Sexual Activity, and Sexual Dysfunctions Aging is one of most powerful predictors of changing sexual functioning 2007 findings of over 3,000 57-85 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

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

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

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

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

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.

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

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

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

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: – 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

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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