1. Presented by: Floyd Wood, FRCPC Date: March 23, 2016 Assisted by Dr. B. Booth’s review course lecture SEXUAL FUNCTION & DYSFUNCTION BACK TO BASICS University of Ottawa

2.  To learn about normal sexual function and factors that affect function  Learn about each category of Sex Disorders listed in DSM-5  Sexual Dysfunctions  Gender Dysphorias  Paraphiliic Disorders  Overview of treatment of each disorder as we go along LEARNING OBJECTIVES

3. INTRODUCTION

4.  Sexual deviation often comes to a Forensic Psychiatrist  Pedophiles  Rapists  Exhibitionists  Voyeurs  Frotteurs/ Toucheurs  Pornography violations WHY FORENSICS & SEXUALITY?

5.  Sexual Identity = biologic  Gender Identity = Social  by 2-3yo a sense that “I’m a boy” or “I’m a girl” is firmly set; sense of masculinity & femininity develop based on biology, parental & cultural attitudes  Gender Role  Those things which define one as boy/man or girl/woman, built up over life  Sexual Orientation  Object of person’s sexual attraction - hetero, homo or bi DEFINITIONS

6.  Biological  Genes, hormones, physical issues, brain function  Psychological  Self esteem, unresolved dynamic conflicts, Cognitions  Social  Family values, religious beliefs, cultural proscriptions BASIS OF SEXUALITY

7. SEXUAL FUNCTION

8. Women Men HUMAN SEXUAL RESPONSE

9. AGING AND SEXUAL FUNCTION

10.  Think of the stages of sexual function as:  Libido  Arousal  Orgasm DISEASES AND SEX

11. DRUGS AND SEX

12. SEXUAL DYSFUNCTIONS

14. Sexual Dysfunctions “Do you have any concerns about your sexual function?” “How often?” (75% or more = important)

15.  Sexual Desire Disorders  Female Sexual Interest / Arousal Disorder  Male Hypoactive Sexual Desire Disorder  Sexual Arousal Disorders  Female Sexual Interest / Arousal Disorder  Male Erectile Disorder  Orgasmic Disorder  Female Orgasmic Disorder  Delayed Ejaculation  Premature (early) Ejaculation  Sexual Pain Disorders  Genito-Pelvic Pain / Penetration Disorder DSM-5 DIAGNOSES (1) Specifiers for all Dx: 1)Lifelong vs. Acquired 2)Generalized vs. Situational 3)Mild, Moderate, Severe

16.  Substance / Medication-Induced Sexual Dysfunction  Specify if: With onset during intoxication, With onset during w/d, With onset after medication use  Other Specified Sexual Dysfunction  Unspecified Sexual Dysfunction DSM-5 DIAGNOSES (2)

17. FEMALE SEXUAL INTEREST / AROUSAL DISORDER

18.  Most common sexual complaint in women  33% of women and 16% of men (most were acquired)  Complex evaluation and treatment  Self-esteem, body image, stress levels, energy levels med use (SSRI’s), current sexual context, mental health  ? Testosterone  SWAN study (Santoro 2005) 3000 women found minimal correlation b/w desire, arousal & androgen levels; however, some studies suggest on an individual basis. Similar results in men  ? Buproprion  Cochrane review suggested 1 of 2 RCT’s there was benefit (Rudkin, Taylor & Hawton 2004) FEMALE SEXUAL INTEREST / AROUSAL DISORDER

19. MALE HYPOACTIVE SEXUAL DESIRE DISORDER

20.  Prevalence varies depending on country of origin and method of assessment  ~ 6% of younger men (18-24 y/o)  41% of older men (ages 66-74 y/o)  However, a persistent lack of interest (i.e. 6 months) affects only a small proportion of men ages 16-44 (1.8%)  Likely due to shifting interests, evn’t and partners MALE HYPOACTIVE SEXUAL DESIRE DISORDER

21. MALE ERECTILE DISORDER

22.  Most common male sexual complaint  10-20% of all males  50% of all males treated for a sexual disorder  Lifelong ED is rare – 1% < 35 y/o  Causes of ED  Psychogenic (psych illness, psychosocial problems) – 20-50%  Neurogenic  Vascular  Drugs  Systemic illnesses  Localized issues MALE ERECTILE DISORDER

23.  Treatment of ED  Therapy (psychosexual, couple, CBT)  Lifestyle modification  Decreases in EtOH, weight, smoking  Increase in exercise  PDE-5 inhibitors (sidenifil, bardenifil, tadalafil) MALE ERECTILE DISORDER

24.  Prevalence varies widely from 10 to 42% (DSM-5)  Most studies don’t include distress – a proportion of women do not report distress with lack of orgasms so would not meet criteria FEMALE ORGASMIC DISORDERS

25.  Prevalence of 20-30% of all males b/w 18-70 y/o showing concern about how quickly they ejaculate  New defn of 1 minute will likely decrease it to 1-3%  Tx w/ SSRI’s and therapy PREMATURE EJACULATION

26.  Prevalence is unclear due to lack of precise defn  About 1% will persistently complain of lack of ejaculation for 6 mts DELAYED EJACULATION

27.  Prevalence is unknown but ~15% of women in North America will endorse recurrent pain during intercourse  30% of genital sx cause pain: pelvic pathology common GENITO-PELVIC PAIN / PENETRATION DISORDER

28. SUBSTANCE / MEDICATION-INDUCED SEXUAL DYSFUNCTION

29.  What do you do if it is an antidepressant (for MDD) causing the decreased sexual desire /arousal / orgasm?  What are the tx approaches?

30. PSYCHOLOGICAL CAUSES OF SEXUAL DYSFUNCTION

31.  Performance anxiety/fear of inadequate performance  Spectatoring/critically monitoring one’s own sexual performance  Inadequate communication with partner regarding sex  Fantasy  Absence of Fantasy  Distracting Thoughts  Antifantasy fantasies incompatible with sexual arousal IMMEDIATE CAUSES

32.  Intrapsychic Issues  Early conditioning, sexual trauma  Depression, anxiety, guilt, fear of intimacy or separation  Relationship Issues  Lack of trust, power and control issues, anger at partner  Sociocultural factors  Attitudes and values, religious beliefs  Educational & Cognitive  Sexual myths (gender roles, age and appearance, proper sexual activity, expectations)Sexual ignorance DEEPER CAUSES

33. TREATMENT APPROACH

34.  Do a biopsychosocial approach regarding causes and tx plan  Consult other specialties if needed (i.e. obs/gyne, uro)  Treat other psych illness first (i.e. anxiety) TREATMENT (1)

35. BIOPSYCHOSOCIAL CauseTreatment Biological Psychological Social

36. TREATMENT (2)

37. GENDER DYSPHORIA

38. DSM-5 DIAGNOSTIC CRITERIA CHILDREN (1)

39. DSM-5 DIAGNOSTIC CRITERIA CHILDREN (2)

40. DSM-5 DIAGNOSTIC CRITERIA ADULTS (1)

41. DSM-5 DIAGNOSTIC CRITERIA ADULTS (2)

42.  Intersex Conditions  Turner’s (XO) – results in absence/minimal gonads; no sig sex hormones, body remains in resting F state, due to missing X chromo, F development also incomplete  Klinefelter’s (XXY) – usu M body, but effect of Y is weakened by extra X; small testes,  gynecomastia  Adrenogenital syndrome (congenital virilizing adrenal hyperplasia) - ?both sex organs spectrum  Androgen insensitivity (testicular feminization syndrome) – x-link rec, are F but have cryptochid testes DISORDER OF SEX DEVELOPMENT

43.  Unknown prevalence but 1/30,000 (M) and 1/100,000 (F) present for reassignment surgery  2-3 : 1 (M:F) present in clinics as adults  Etiology  Biology  Default of fetus is F; w/ hormonal effects on sex organs  Post-mortems of 6 ‘transsexuals’ showed F size of red nucleus  Psychosocial  Gender identity = combo of biology, temperament, parents/society attitudes  “delicate/sensitive” temperament in M  “aggressive/energized” temperament in F EPIDEMIOLOGY

44.  Different from autogyenephilia (arousal from idea of being F)  Boys often start to have d/o before 4 y/o  Cross-dressing may also happen (75% will start before 4 y/o)  Persistence  In natal males, persistence has ranged from 2.2% to 30%  In natal females, persistence has ranged from 12% to 50%.  ? “watchful waiting” approach (?distress)  Transexualism (i.e. desire for sex reassignment) occurs in <10% of gender dysphoria patients CLINICAL

45. SEXUAL ORIENTATION

46. PARAPHILIAS

48.  Sex crimes are common:  1/6 american fm victims of attempted or completed sexual assault  3% of men  Child Sexual Abuse:  12-27% girls  8-16% of boys SCOPE OF THE PROBLEM

49.  Voyeuristic disorder  Exhibitionistic disorder  Frotteuristic disorder  Sexual masochism disorder  Sexual sadism disorder  Pedophilic disorder  Fetishistic disorder  Travestic disorder  Other specified paraphilic disorder  Unspecified paraphilic disorder PARAPHILIAS IN DSM-5

50.  Recurrent, intense, sexually arousing fantasies, sexual urges or behaviours involving:  Nonhuman objects, suffering or humiliation, children or other non- consenting person (i.e. DD/ID person)  Cause significant distress if not acting out on urges  Occur > 6 months WHAT IS A PARAPHILIA?

52.  Unknown prevalence  F <<<< M  Onset usually late teens, early adulthood EPIDEMIOLOGY

53. TRANSINSTITUTIONALIZATION

54. PARAPHILE VS SEXUAL OFFENDER

55.  Are very common  Most don’t come to clinical or legal attention  Paraphilia ≠ sex offender  Paraphilia ≠ guilty PARAPHILIAS

56.  94 men in community  62% fantasized about initiating sex with a “young girl”  33% fantasized about rape of a woman  Study of 193 male undergraduates  21% reported sexual attraction to children 9% fantasized about sex with children  5% masturbated to fantasies of sex with children  Study of 60 undergrads  42% reported voyeurism, 54% reported a desire  35% reported frottage PARAPHILIAS IN NON-OFFENDERS

57.  Journal of Clinical Psychiatry (convicted SO’s)  85 % with SUD (62% with both alcohol and drug abuse)  74% with paraphilia (37% with pedophilia; other majority fall under NOS category)  58% with mood disorder (34% with bipolar d/o; type I > II)  38% with Impulse Disorder (20.4% with Intermittent explosive disorder)  23% with Anxiety Disorder (9.7% with social phobia; 8.8% with PTSD)  9% with eating disorder (8% with binge-eating d/o)  Avoidant personality d/o was sig more associated with paraphilic sex offenders than non-paraphilic sex offenders RATES OF ILLNESS IN SEXUAL OFFENDERS (1)

58. RATES OF ILLNESS IN SEXUAL OFFENDERS

59.  Unknown!!!  Psychological theories  Psychoanalytic – Castration fears, no supporting scientific evidence  Behavioural – learned via classical cond and operant cond,(early sexualiation) used for tx designs  Lovemap – early trauma (abuse, incest) vandalizes the template of what particular stimuli arouse an individual; some correlational support  Courtship D/O – disruption in the normal processes of locating a suitable partner, appropriate display of sexual interest and genital union minimal research support  Feminist – paraphilias as dominance and aggressive behaviours that subordinate women and limit their freedom minimal research support  Biology  Mixed findings hormone level abn, brainstem malfn, neurochemical imbalances  Difficult to know if abnormalities preceded or followed paraphilic b.  Evolution CAUSES OF PARAPHILIAS

60.  “Driving” Factors  Paraphilias (preferential arousal, exclusive arousal, some drugs/alcohol may enhance)  Hypersexuality/High Sex Drive (preoccupation can  sexually diverse interests, some drugs  drive)  Need for acceptance/social network (lack social skills or can’t establish normal relationships)  “Disinhibiting” Factors  Impaired Judgment (alcohol/drugs, brain injury, mental d/o, developmental delay)  Cognitive Distortions (distorted values ?d/t own sex abuse; distorted values re: victims – i.e. =objects)  Empathy Deficits (psychopathy)  Social Deficits (i.e. ID/DD, MR – more acceptance by children; or can manipulate children)  Life Situations (work problems, relationship problems) CAUSES OF SEXUAL OFFENDING

61. PEDOPHILIC DISORDER IN DSM-5

62.  < 3% of the population  95% identify as heterosexual  50% have consumed alcohol at time of offence  >90% are men  Many have also done exhibitionism, voyeurism & rape  Often feel more accepted by kids, have low self-esteem, or body image problems EPIDEMIOLOGY

63.  Anxiety  Depression  Substance abuse  Personality problems  Mental Retardation  Other paraphilias  Exhibitionism  Voyeurism PEDOPHILIA COMORBIDITY

64.  Learning theory  Masturbatory conditioning  Cycle of Sexual Abuse  Cause distorted ideas  Neurodevelopmental D/O  Frontal lobes, brain injures  Left-handedness, IQ  Cognitive Distortions supportive of child molesting CAUSES OF PEDOPHILIA

65.  EXTERNAL CONTROL  Incarceration (can include indeterminate sentencing; option of long-term offender or dangerous offender)  Release conditions (sex offender registry, community notification, and castration)  Civic commitment (not in Canada yet)  REDUCE SEX DRIVE  Partial sex drive reduction (SSRI’s)  Ablation of testosterone (Cyproterone (Androcur), Medroxyprogesterone (provera))  Indirect inhibition of other sex hormones (Leuprolide (Lupron), Gosserelin (Zoladex))  Inhibit peripheral testosterone (adjunct) (Finasteride) TREATMENT (1)

66.  External Control  Reduce Sex Drive  Treat comorbidities  Psychotherapy TREATMENT

67.  General Workup TREATMENT (2)

68.  Cyproterone (Androcur)  Testosterone antagonist  100-500 mg/d PO; or 100-600 mg/wk IM  Contraindicated in liver dz & thromboembolic  15-50% get gynecomastia (estrogen increase)  Increase weight, decrease body hair  Risk of fatigue or depression  Reoffense rate of 6% TREATMENT (3)

69.  Medroxyprogesterone (Provera)  Negative feedback to FSH & LH (decrease Testosterone)  100-600 mg/d or 100-700 mg/wk IM  Contraindicated in liver dz & thromboembolic  SE = hot flashes, impotence, sweating, fatigue, HTN, edema  Increase weight, appetite  Mild depression, fatigue  Re-offense rate is practically zero TREATMENT (4)

70.  Leuprolide (Lupron) / Goserelin (Zoladex)  High levels of GnRH (agonist)  3.75 – 7.5 mg/mt IM (Lu); 3.6 mg/mt IM (Zo)  Contraindicated in bone demineralization d/o or hypersensitivity to drugs  Hot flashes (60%), impotence, sweating, rash, edema (3%), myalgia, decreased bone density  Decreased recidivism/re-offense TREATMENT (5)

71.  TREAT COMORBIDITIES  Depression, mania  SCZ, Substances  Relational problems  Don’t treat “Manopause”  PSYCHOTHERAPY  CBT (correct cognitive distortions, esp in group)  Covert sensitization (imagine –ve social consequences, can also write/view read outloud)  Masturbatory conditioning (satiation)  Olfactory aversion (ammonia paired w/ deviant stimuli)  Relapse prevention group (teach triggers & precursers leading up to deviant b.)  Social skills group  Self-regulation groups (cope w/ stressors that trigger) TREATMENT (6)

72.  Very low when compared to other offenders  Overall 5-yr recidivism = 13.4%  12.7% for child molesters  18.9% for rapists  Incest offenders the lowest at 4-10%  Prenky et al gave a 25 yr rate of  39% for rapists  53% for extrafamilial child molesters RECIDIVISM

73. PROGNOSIS

74.  Includes all other paraphilias  Literally hundreds of kinds  Some come to the attention of the legal authorities OTHER SPECIFIED PARAPHILIC DISORDES

75. TELEPHONE SCATALOGIA

76. NECROPHILIA

77. ZOOPHILIA

78.  Abasiophilia - People with impaired mobility  Acrotomophilia - People with amputations  Agalmatophilia - Statues, mannequins and immobility  Algolagnia - Pain, particularly involving an erogenous zone; differs from masochism as there is a biologically different interpretation of the sensation rather than a subjective interpretation  Andromimetophilia- Female-to-male transsexuals; also known as gynemimetophilia  Apotemnophilia - Having an amputation  Asphyxiophilia - Asphixiation or strangulation  Autagonistophilia - Being on stage or on camera  Autassassinophilia - Being in life-threatening situations  Autoandrophilia - Arousal by a biological female imagining herself as a male  Autoerotic asphixiation -Self-induced asphyxiation, sometimes to the point of near unconsciousness  Autogynephilia - Arousal by a biological male imagining himself as a female  Autopedophilia - Being prepubescent  Biastophilia - Arousal based on the rape of an unconsenting person, also rapism  Chremastistophilia - Being robbed or held up  Chronophilia - Partners of a widely differing chronological age  Coprophilia - Feces; also known as scat, scatophilia or fecophilia OTHERS

79.  Dacryphilia - Tears or crying  Dendrophilia - Trees  Emetophilia - Vomit  Erotic asphyxiation - Asphyxia of oneself or others  Erotophonophilia - Murder  Exhibitionism - Exposing oneself sexually to others, with or without their consent  Formicophilia - Being crawled on by insects  Frotteurism - Rubbing against a non-consenting person  Gerontophilia - Elderly people  Gynandromorphophilia - Women with penises, men cross-dressed as women, or male-to-female transsexuals  Hebephilia - Adolescents/Pubescent children  Homeovestism - Wearing clothing emblematic of one's own sex  Hybristophilia - Criminals, particularly for cruel or outrageous crimes  Infantophilia - Children five years old or younger  Kleptophilia - Stealing; also known as kleptolagnia  Klismaphilia - Enemas  Lactaphilia - Breast milk  Liquidophilia - Attraction, or desire to immerse genitals in liquids  Macrophilia - Giants, primarily domination by giant women or men OTHERS

80.  Mammaphilia - Breasts; also known as mammagynophilia and mastofact  Masochism - The desire to suffer, be beaten, bound or otherwise humiliated  Menophilia - Menstruation  Morphophilia - Particular body shapes or sizes  Mucophilia - Mucus  Mysophilia - Dirtiness, soiled or decaying things  Narratophilia - Obscene words, colloquially known as "talking dirty"  Nasophilia - Noses  Necrophilia - Cadavers  Olfactophilia - Smells  Paraphilic infantilism - Being a baby; also referred to as autonepiophilia  Partialism - Specific, non-genital body parts  Pedophilia - Prepubescent children, also spelled paedophilia  Peodeiktophilia - Exposing one's penis  Pedovestism - Dressing like a child  Pictophilia - Pornography or erotic art, particularly pictures  Pyrophilia - Fire  Raptophilia - Committing rape  Sadism - Inflicting pain/suffering on others  Salirophilia - Soiling or dirtying others OTHERS

81.  Scoptophilia - Observing others' sexual activities; also known as scopophilia and more commonly as voyeurism  Sexual fetishism - Nonliving objects  Somnophilia - Sleeping or unconscious people  Sthenolagnia - Muscles and displays of strength  Stigmatophilia - Body piercings and tattoos  Symphorophilia - Witnessing or staging disasters such as car accidents  Telephone scatologia - Obscene phone calls, particularly to strangers; also known as telephonicophilia  Transvestic fetishism - Wearing clothes associated with the opposite sex; also known as transvestism  Transvestophilia - A transvestite sexual partner  Trichophilia - Hair  Troilism - Cuckoldism, watching one's partner have sex with someone else, possibly without the third party's knowledge; also known as triolism  Urolagnia - Urination, particularly in public, on others, and/or being urinated on  Ursusagalmatophilia - Teddy bears  Vampirism - Drawing or drinking blood; also known as murphyism  Vorarephilia - Eating or being eaten by others; usually swallowed whole, in one piece OTHERS

82.  Voyeurism - Watching others while naked or having sex, generally without their knowledge  Zoophilia - Animals (actual, not anthropomorphic)  Zoosadism - Inflicting pain on or seeing animals in pain OTHERS

83. Yes Virtually all studies have found that treatment significantly decreases recidivism DOES TREATMENT WORK?

84.  Sex Offences are common  Many Sex Offenders have paraphilias  Most paraphiles don’t commit crimes  Most Sex Offenders don’t re-offend  Sex Offenders are treatable through external control, medications and psychotherapy SUMMARY