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)