1. Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders14
Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders

2. What is “Normal” Sexual Behavior?
Understanding what is normal
Important when classifying or diagnosing sexual problems and behaviors
Difficult to determine what is normal
Example: people report tremendous variation in frequency of sexual outlet or release
Influenced by cultural norms and values
Definitions of sexual disorders are inexact

3. Defining Sexual Behavior as a Mental Disorder
Controversy surrounding definition of deviant sexual behavior
Some argue that sexual behavior is only deviant if it threatens society, causes distress to participants, or impairs social or occupational functioning
Greater controversy regarding whether gender dysphoria should be considered a psychiatric disorder

4. The Sexual Response Cycle
Appetitive phase
Characterized by person’s interest in sexual activity
Arousal phase
May follow or precede the appetitive phase
Heightened when specific, direct sexual stimulation occurs
Various physical changes occur
Example: increased blood flow to penis in males

5. The Sexual Response Cycle (cont’d.)
Orgasm phase
Characterized by involuntary muscular contractions throughout the body and eventual release of sexual tension
Resolution phase
Characterized by relaxation of the body after orgasm
Heart rate, blood pressure, and respiration return to normal

6. Human Sexual Response Cycle
Figure 14.1 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.

7. Sexual Dysfunctions
Recurrent and persistent disruption of any part of the normal sexual response cycle
DSM-5 requires that symptoms be present for at least six months and be accompanied by significant distress
Types of dysfunctions
Lifelong
Acquired
Generalized
Situational

8. Lifetime Prevalence of Sexual Disorders in the United States (40–80 Age Range)
Table 14.2 Lifetime prevalence of sexual disorders in men and women in the age range for the United States

9. Sexual Interest/Arousal Disorders
Problems with sexual excitement in the appetitive and arousal phases
Male hypoactive sexual desire disorder
Little or no interest in sexual activities
Female sexual interest/arousal disorder
Little or no interest, or diminished arousal to sexual cues
40-50 percent of all sexual difficulties involve deficits in interest

10. Sexual Interest/Arousal Disorders (cont’d.)
DSM-5 diagnosis for sexual dysfunction not appropriate when severe relationship problems, mental disorders, or significant stressors play a role
Individuals often capable of experiencing orgasm
Little interest in, or derive minimal pleasure from sexual activity

11. Erectile Disorder
Inability to attain or maintain an erection sufficient for sexual intercourse or other sexual activity
Studies show up to 70 percent of erectile dysfunction is due to limited blood flow
Distinguishing between biological and psychological causes is often difficult
Distinction may be made based on presence or absence of nocturnal penile tumescence

12. Orgasmic Disorders Female orgasmic disorder Delayed ejaculation
Persistent delay or inability to achieve orgasm despite receiving adequate sexual stimulation
Marked reduced intensity of orgasmic sensation
Delayed ejaculation
Persistent delay or absence of ejaculation after excitement phase is reached

13. Premature Ejaculation
Distressing and recurrent pattern of having an orgasm with minimal sexual stimulation before, during, or after vaginal penetration
Must occur within one minute of penetration
Most common sexual dysfunction
Affects percent of men

14. Genito-Pelvic Pain/Penetration Disorder
Involves physical pain or discomfort associated with intercourse/penetration
Dyspareunia
Pain in the pelvic region during intercourse
Vaginismus
Involuntary spasm of the outer third of the vaginal wall
Prevents or interferes with sexual intercourse

15. Aging and Sexual Dysfunctions
Changes in sexual function common as we age
Menopause
Women’s estrogen levels drop
Vaginal dryness and thinning of the vaginal wall
Older men at increased risk for prostate problems and cardiovascular difficulties
May increase risk of ED

16. Etiology of Sexual Dysfunctions
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
Many antidepressant and antihypertensive medications
Alcohol as leading cause of disorders
Illnesses and other physiological factors

17. Multipath Model of Sexual Dysfunctions
Figure 14.2 Multipath model of sexual dysfunctions

18. Etiology of Sexual Dysfunctions (cont’d.)
Psychological dimension
Predisposing or historical factors
Current problems and concerns
Presence of anxiety disorders
Performance anxiety and spectator role
Role of early sexual experiences
Situational or emotional anxiety for women
Negative thoughts and dysfunctional beliefs

19. Etiology of Sexual Dysfunctions (cont’d.)
Social dimension
Social upbringing and current relationships
Strict religious upbringing
Traumatic sexual experiences
Relationship issues often forefront of sexual disorders
Marital satisfaction associated with greater sexual frequency

20. Etiology of Sexual Dysfunctions (cont’d.)
Sociocultural dimension
Influenced by gender, age, cultural scripts, sexual orientation
Examples of sociocultural aspects
People in Asian countries consistently report lowest frequency of sexual intercourse
Cultural scripts for men in the United States
Sexual potency as a sign of masculinity
Homophobia toward lesbians or gays

21. Treatment of Sexual Dysfunctions
Biological interventions
Hormone replacement
Special medications
Mechanical means to improve functioning
Vacuum pumps, suppositories, penile implants
For ED, injecting medication into penis
Oral medications (Viagra, Levitra, Cialis)
Psychological boost may lead to feelings of enhanced pleasure

22. Psychological Treatment Approaches
Education
Replace myths and misconceptions with facts
Anxiety reduction
Desensitization or graded approaches
Changing negative thoughts and beliefs
Structured behavioral exercises
Tasks that gradually increase amount of sexual interaction
Communication training

23. Gender Dysphoria
Previously called gender identity disorder (GID) or transsexualism
Marked incongruence (mismatch) between one’s experienced or expressed gender and biologically assigned gender
Not the same as sexual orientation
Diagnosed when there is significant distress or impairment
Experienced differently at different ages

24. Etiology of Gender Dysphoria
Etiology is unclear
Research has focused on other sexual disorders
Likely an interaction of multiple variables
Most transgender children have normal hormone levels
No specific neurological explanation
Brain alterations associated with psychosocial distress and social exclusion

25. Psychological and Social Influences
Explanations must be viewed with caution
Hypothesis
Childhood experiences influence development of gender dysphoria
Parent encouragement of feminine behavior, overprotection, lack of male role models, etc.
Psychosocial stressors
Stigma and lack of societal acceptance play a role in distress and impairment associated with gender dysphoria

26. Treatment of Gender Dysphoria
Gender reassignment therapies
Changing physical characteristics through hormone therapy or surgery
Many involve reconstructing genital organs
Some insurance beginning to include coverage for transgender individuals
Studies show positive outcomes
Some risk remains for psychiatric difficulties, including suicidality

27. Paraphilic Disorders DSM-V definition
Sexual interest in non-normative targets
May involve unusual erotic behavior or socially unacceptable targets
Diagnosed only when paraphilia harms, or risks harming others and is acted on
Or causes the individual to experience distress or impairment in social functioning

28. Paraphilic Disorders
Table 14.6 Paraphilic disorders

29. Paraphilic Disorders Involving Nonhuman Objects
Fetishistic disorder
Extremely strong sexual attraction and fantasies involving inanimate objects
Examples: shoes or undergarments
Person is often sexually aroused to the point of erection in the presence of the fetish item
Person may choose sexual partners on the basis of having that item
Must cause significant distress or harm to others

30. Transvestic Disorder
Intense sexual arousal associated with cross-dressing (wearing clothes appropriate to the opposite gender)
Do not confuse with gender dysphoria
Most people who cross-dress are exclusively heterosexual
Incidence higher among men than women
Men may become sexually aroused by thoughts of themselves as female

31. Paraphilic Disorders Involving Nonconsenting Persons
Exhibitionistic disorder
Urges, acts, or fantasies of exposing one’s genitals to strangers, intent to shock
Voyeuristic disorder
Urges, acts, or fantasies involving observation of an unsuspecting person disrobing or engaging in sex activity
Diagnosed only in those age 18 or older
Individual must be distressed by or have acted on the voyeuristic urges

32. Frotteuristic Disorder
Recurrent/intense sexual urges, acts, or fantasies of touching or rubbing against a nonconsenting person
For diagnosis, person must be markedly distressed by urges or have acted on them
Prevalence is difficult to determine
Behavior may go unnoticed or presumed to be accidental

33. Pedophilic Disorder
Adult obtains erotic gratification through urges, acts, or fantasies involving children under the age of 13
Sexual abuse of children is common
15 percent of girls and six percent of boys
Most people who act on pedophilic urges are friends, relatives, or acquaintances of their victims
Effects of sexual abuse can be lifelong

34. Paraphilic Disorders Involving Pain or Humiliation
Sexual masochism disorder
Sexual urges, fantasies, or acts that involve being humiliated, bound, or made to suffer
Individual does not seek harm or injury
Finds sensation of helplessness appealing
Sexual sadism disorder
Sexual urges, fantasies, or acts that involve inflicting physical or psychological suffering on others

35. Etiology and Treatment of Paraphilic Disorders
We still have much to learn
Some research findings conflict with each other
Some men may be biologically predisposed to pedophilic disorder
Psychological factors also contribute
Paraphilias may result from accidental associations between certain situations and sexual arousal

36. Behavioral Approaches to Treatment
Weakening or eliminating sexually inappropriate behaviors through extinction or aversive conditioning
Acquiring or strengthening sexually appropriate behaviors
Developing appropriate social skills
Aversive behavior rehearsal for exhibitionism

37. 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 psychological disorder
Number of rapes in the U.S. has risen dramatically
One in five adult women has been raped
One in 71 men

38. Characteristics of Male Rapists
Create situations in which sexual encounters may occur
Misinterpret friendliness as provocation and protests as insincerity
Manipulate women into sexual encounters with alcohol (70%) or other drugs
Attribute failed attempts at sexual encounters to perceived negative features of the woman

39. More Characteristics of Male Rapists
Come from environments of parental neglect or physical or sexual abuse
Initiate coitus earlier in life than men who are not sexually aggressive
Have more sexual partners than non- sexually aggressive men

40. Date Rape
Between eight and 25 percent of female college students report having “unwanted sexual intercourse”
Many reluctant to report
Many universities conducting workshops to encourage understanding that intercourse without consent is rape

41. Effects of Rape Rape trauma syndrome symptoms
Include psychological distress, phobic reactions, post-traumatic stress symptoms, and sexual dysfunction
Phases in rape trauma syndrome
Acute phase: disorganization
Feelings of self-blame, fear, or depression
Long-term phase: reorganization
Survivors deal directly with feelings and attempt to reorganize their lives

42. Etiology of rape Power rapist: 55 percent of rapists
Compensate for feelings of personal/sexual inadequacy by trying to intimidate victims
Anger rapist: 40 percent of rapists
Angry at women in general
Sadistic rapist: 5 percent of rapists
Derives satisfaction from inflicting pain
May torture or mutilate victims

43. Etiology of Rape (cont’d.)
Rape has more to do with power, aggression, and violence than sex
Sexual motivation also plays a role in rape
Most rape survivors are in their teens or 20s
Age range associated with sexual attractiveness
Most rapists name sexual motivation as primary reason for actions
Many rapists have multiple paraphilias

44. Etiology of Rape (cont’d.)
Effects of pornography and media portrayals of violent sex may affect rape prevalence
“Cultural spillover” theory
Rape is high in environments that encourage violence
United States has highest rape rate among countries reporting rape statistics

45. Treatment for Rapists
Many believe sex offenders are not good candidates for treatment
Most common penalty is imprisonment
High recidivism rates
When intervention occurs, it usually incorporates behavioral techniques
Some treatment techniques show success with exhibitionists and child molesters
Outcomes tend to be poor for rapists

46. Contemporary Trends and Future Directions
DSM-5 has made a clear distinction between paraphilias and paraphilic disorders
May change societal views on sexual differences that are not harmful to others
Gender dysphoria may eventually be removed as a psychiatric diagnosis
Sweden has removed transvestism, fetishism, and sadomasochism from list of mental illnesses

47. Review What are normal sexual behaviors?
What do we know about normal sexual responses and sexual dysfunction?
What causes gender dysphoria, and how is it treated?
What are paraphilic disorders, what causes them, and how are they treated?
Is rape an act of sex or aggression?