1. Sexual Dysfunctions and Paraphilic Disorders
Chapter 15
Sexual Dysfunctions
and Paraphilic Disorders

2. Sexual Disorders: Introduction
DSM-5 classification
Sexual dysfunctions
Paraphilias
Previous DSM classification systems used Masters and Johnson’s four-stage human sexual response cycle
Major criticisms were related to the linear conceptualization of this model
New view system
Disorders of sexual dysfunction are now listed in alphabetical order in that no underlying model of sexual response has been agreed-upon

3. DSM-5 Diagnoses of Sexual Dysfunction
Delayed ejaculation
Erectile disorder
Female orgasmic disorder
Female sexual interest/arousal disorder
Genito-pelvic pain/penetration disorder
Male hypoactive sexual desire disorder
Premature (early) ejaculation
Substance-/medication-induced sexual dysfunction
Other specified; unspecified

4. Diagnostic Considerations
Each sexual dysfunction disorder may be specified as being lifelong versus acquired and general versus situational
DSM-5 also lists five associated features
Partner factors
Relationship factors
Individual vulnerability factors
Cultural/religious factors
Medical factors
DSM-5 has added a minimum duration (Criterion B) of 6 months to decrease diagnosis of temporary conditions

5. Epidemiology The National Health and Social Life Survey
Total prevalence for sexual difficulties
43% in women and 31% in men
Figures may be inflated because distress was not studied
African American women reported lower levels of sexual desire and pleasure than did Caucasian women
Caucasian women reported more sexual pain than did African American women
Both Caucasian and African American women had higher rates of sexual difficulty than did Hispanic women

6. Epidemiology cont.
Being married and having higher education were each associated with lower rates of dysfunction
Emotional or stress-related problems were strongly associated with sexual difficulties
Physical health-related problems were more predictive of sexual dysfunction in men only
A decline in social status was related to an increased risk for all types of sexual difficulty for women, but only with erectile disorder in men
Quality of life significantly predicted sexual difficulties, particularly for women

7. Epidemiology cont. Some prevalence rates based on the NHSLS data:
Low desire in 15% of men and 30% of women
ED in 7% of men aged 18 to 29; 18% in those aged 50 to 59
Female sexual arousal disorder (DSM-IV) ranged from 11% to 31%
Premature ejaculation affects approximately 30% men 18 to 59 (most prevalent male dysfunction)
Delayed ejaculation is much less prevalent (2–8%)
Methodological concerns— “medicalization”

8. Psychological and Biological Assessment
Is the problem related to a psychological versus a biological/organic etiology, or both?
Clinical interview
Mood and general psychiatric status
Medications and medical comorbidities
Psychosexual history
Personal history

9. Etiology
All of the sexual dysfunctions are considered to be biopsychosocial in their etiology
Specifiers “due to psychological factors” and “due to combined factors” have been eliminated from DSM-5
27% to 62% of women with low desire also meet criteria for a depressive disorder
Cultural influences
Lower levels of desire in women from East Asian heritage compared to women from European descent
“Sex guilt” may be a mediating factor in cultural differences
Hormonal imbalances
Performance anxiety
Genetic factors
Alcohol usage

10. Treatment
Much research attention has been focused on finding effective pharmacological treatments for the most prevalent sexual complaints (i.e., low desire in women, erectile and ejaculation difficulties in men)
As a result, there is a paucity of randomized controlled trials of psychological treatments
Typically, treatment can include:
Medications
Hormonal therapy
Psychotherapy

11. Paraphilias: Introduction
Paraphilias, as defined in the DSM-5, refer to “any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners”
Term paraphilia translates into love (philia) beyond the usual (para)
Two main types:
Anomalous activity preferences
Anomalous target preferences

12. Paraphilias: Introduction cont.
Paraphilias and sexual offending are not mutually exclusive, but do not necessarily co-occur
Much of the research on paraphilias has been based on samples of convicted sexual offenders
Confounds
Many sexual offenders were never formally diagnosed with a paraphilia
Generalizability (more severe end of spectrum)
Veracity of self-reports (want to look less deviant)

13. DSM-5 Diagnoses Exhibitionistic disorder Fetishistic disorder
Frotteuristic disorder
Pedophilic disorder
Sexual masochism disorder
Sexual sadism disorder
Transvestic disorder
Voyeuristic disorder
Otherwise specified/unspecified

14. Diagnostic Considerations
Paraphilias and paraphilic disorders are not the same thing; paraphilia is a necessary but not sufficient for diagnosis, may not cause distress or require clinical intervention
DSM-5 specifiers added: In a controlled environment and in full remission
Paraphilias must be distinguished from:
Nonpathological sexual interests
Other paraphilias (transvestic and fetishistic)
Comorbidity of paraphilias is high
Paraphilias need to be distinguished from other nonparaphilic disorders (transvestic disorder and gender dysphoria)

15. Epidemiology
The incidence and prevalence of the paraphilias is unknown due to their secretive and often illegal nature
Frequency estimates are generally based on small, nonrepresentative samples (often involving convicted sexual offenders)
Exhibitionism is one of the the most common paraphilias and may be the most common sexual offense (one-third to two-thirds sexual offenses in Canada, United States, and Europe)
Fetishism is a rare condition (0.8%)
Frotteurism may be more common than once believed

16. Epidemiology cont. Pedophilia prevalence is unknown
Upper limit has been extrapolated to be about 5% (3-9% of men in a convenience sample self-reported fantasies or sexual contact involving prepubescent children)
5% to 10% of the population has engaged in some form of masochistic activity; less than 1% on a regular basis
In sexual offenders, rates of masochism range from 2% to 5%; sexual sadism ranged from 4% to 9%
In nonclinical samples, 5% of men and 2% of women admitted becoming sexually aroused to inflicting pain on others
Voyeurism is also common and is a common sexual offense

17. Psychological and Biological Assessment
Assessment strategies include:
Self-report measures (Clark Sexual History Questionnaire; Multiphasic Sex Inventory; Wilson Sex Fantasy Questionnaire)
Phallometric assessment
Polygraph
Measures of visual reaction time
Challenges in assessment include:
Privacy
Stigma

18. Etiology
Numerous theories have been proposed to explain how the paraphilias develop; however, empirical evidence is either lacking or contradictory
Neuroanatomy/neurobiology
Learning, modeling, and life events
Cognitive influences

19. Course, Prognosis, and Treatment
Course is typically chronic
Severity of sexual sadism tends to increase over time
There is a lack of empirical support that treatment for sexual offenders is superior to a placebo
Treatment with non-offending individuals focuses on health, safety, overcoming impairment