1. Clinical and Forensic Psychologist
Advanced Psychopathology – PSY 306 Sexual Deviance and Sexual Dysfunction
Katie Seidler
Clinical and Forensic Psychologist
Macquarie University, 2007

2. Sexual Deviance and Dysfunction
Introductions
Lecture Outline
What is normal sexual behaviour?
What constitutes deviance?
What is the difference between deviance and dysfunction?
The distinction between fantasy and behaviour.

3. Sexual Deviance and Dysfunction
Lecture outline continued…
Diagnostic definitions of deviance.
Defining features,
Prevalence,
Gender difference,
Comorbidity.
DSM-IV categories of sexual deviance.
Theories of deviance.
Clinical issues in dealing with sexual material.
Definitions of sexual dysfunction.

4. Sexual Deviance and Dysfunction
Lecture outline continued…
DSM-IV categories of sexual dysfunction.
Prevalence,
Comorbidity,
Clinical issues,
Psychosocial issues.

5. Sexual Deviance and Dysfunction
Small Group Discussion – what is normal sexual behaviour?
Large group discussion – what is the difference between deviance and dysfunction?

6. Sexual Deviance and Dysfunction
Small Group Exercise - Scenarios

7. Sexual Deviance and Dysfunction
It is important to distinguish between fantasy and behaviour.
Deviant fantasies are common.
Fantasy is not illegal but may be concerning, depending on behaviour.
The continuum of sexual aggression.

8. Sexual Deviance and Dysfunction
Sexual Deviance – DSM-IV
Paraphilias are - characterised by recurrent, intense sexual urges, fantasies or behaviours that involve unusual objects, activities or situations and cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

9. Sexual Deviance and Dysfunction
Unusual objects usually involve:
non-human objects (i.e., shoes, hats etc),
the suffering or humiliation of oneself or one’s partner,
children or other non-consenting persons.
Must have persisted for six months or more.
May or may not be illegal.

10. Sexual Deviance and Dysfunction
Tends to develop in adolescence and be refined with age and experience.
Tends to be chronic and lifelong, although frequency and intensity may vary.
Reduces with age, as per “normal” sexual trajectory.
Seems rare – but problems with prevalence research.
Almost exclusively male – except maybe sadomasochism.

11. Sexual Deviance and Dysfunction
Comorbidity:
Relationship problems – i.e., due to the shame, disgust, embarrassment etc that one or both parties in the relationship may experience.
Often associated with a reduced capacity for intimacy and, therefore, other social and sexual problems – including sexual dysfunction.
Many people present with multiple paraphilias.
Personality Disorders.
Other Axis I disorders – for example anxiety and depression and these may be primary to or secondary to the sexual deviance.

12. Sexual Deviance and Dysfunction
Associated issues:
Often illegal.
Most clients will be involuntary for treatment and may be mandated by Courts, external agencies, etc. This will affect engagement and treatment outcome.
Often not associated with distress. Clients often claim the “problem” lies in others’ responses. This is about justifying and normalising their behaviour to alleviate guilt and embarrassment.
Notions of deviance are socially constructed.

13. Sexual Deviance and Dysfunction
Exhibitionism
Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving the exposure of one’s genitals to an unsuspecting stranger.
This may or may not include masturbation.

14. Sexual Deviance and Dysfunction
Fetishism
Over a period of at least six months, current, intense sexually arousing fantasies, sexual urges, or behaviours involving the use of nonliving objects.
E.g., lingerie, shoes, etc.
NB: The fetish objects are not limited to articles of female clothing used in cross-dressing or the devices designed for the purpose of tactile genital stimulation (e.g., a vibrator).
The fetishistic object is usually required or strongly preferred for sexual excitement, such that in its absence, men may experience erectile dysfunction. Person may masturbate to the object or ask partner to wear it.

15. Sexual Deviance and Dysfunction
Frotteurism
Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving touching and rubbing against a non-consenting person.
Usually occurs in crowded place – such as buses, trains etc.

16. Sexual Deviance and Dysfunction
Paedophilia
Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child or children.
NB: Child must be pre-pubescent – generally under 12 (cf hebophilia).
NB: The person is at least age 16 years and at least five years older than the child or children.
Specifiers:
Male children (more likely to recidivate)
Female children
Both
Intrafamilial/extrafamilial
Exclusive interest in children.

17. Sexual Deviance and Dysfunction
Sexual Masochism
Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.
e.g.,
infantilism – being forced to act/dress like a baby,
infibulation – piercing etc
bondage
hypoxyphilia.

18. Sexual Deviance and Dysfunction
Sexual Sadism
Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.
e.g., Jeffrey Dahmer.

19. Sexual Deviance and Dysfunction
Transvestic Fetishism
Over a period of at least six months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving cross-dressing.
Specify:
With Gender Dysphoria – i.e., discomfort with their own gender.
Not if occurs in Gender Identity Disorder
May also include homosexual activity.
May also be engaged in as a form of anxiety management or soothing.

20. Sexual Deviance and Dysfunction
Voyeurism
Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.
i.e., peeping tom stuff – usually involves masturbation.

21. Sexual Deviance and Dysfunction
Paraphilia NOS
That is, anything else.
Can include:
Scatalogia (telephones),
Necrophilia,
Coprophilia,
Zoophilia etc…

22. Sexual Deviance and Dysfunction
Theories of Deviance
1. Inappropriate Arousal
The deviancy becomes reinforced by the sexual pleasure associated with masturbation or sexual behaviour, with the main sustaining variable relating to masturbation and fantasy, which explains why the behaviour does not extinguish in the absence of behavioural reinforcement.

23. Sexual Deviance and Dysfunction

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26. Sexual Deviance and Dysfunction

27. Sexual Deviance and Dysfunction
Problems with the theory:
Most people don’t recall the experiences of pairing with the object and the arousal and there may have only ever been one pairing, which can’t explain the intensity or chronicity of the deviance.
Most people present with multiple paraphilias and this cannot be explained by the “pairing” hypothesis.
Probably many males have accidental pairings with deviant objects so why is the incidence not higher?
Women experience sexual pleasure through orgasm too so why do they not present with paraphilias like men?

28. Sexual Deviance and Dysfunction
2. Poor Relationships
Research suggests that people with sexual deviancy issues tend to be:
Less socially skilled,
Have greater intimacy deficits,
Have poor attachment skills,
Have fewer social skills with opposite sex.

29. Sexual Deviance and Dysfunction
3. Lowered inhibition
Not developmentally delayed but may be neurologically vulnerable – cause or effect?
Most deviant people choose to lower their inhibitions by justifying their behaviour or engaging in distorted thinking that supports the behaviour.

30. Sexual Deviance and Dysfunction
Examples:
I am not hurting anyone (Fetishism).
They don’t even know I’m there (Voyeurism).
She will enjoy it (Frotteurism).
I am teaching him about sex (Paedophilia).
It makes me feel better (Transvestic Fetishism) etc.

31. Sexual Deviance and Dysfunction
Small Group Discussion – as clinicians what do we need to be mindful of in asking sexual questions?

32. Sexual Deviance and Dysfunction
Sexual Dysfunction - DSM-IV
Must cause distress and impairment.

33. Sexual Deviance and Dysfunction
Hypoactive Sexual Desire Disorder
Persistently and recurrently deficient (or absent) sexual fantasies and desire for sexual activity.
Judgement of deficiency or absence is made by the clinician and needs to take into account age, life context etc.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.

34. Sexual Deviance and Dysfunction
Sexual Aversion Disorder
Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner.
The aversion may be manifest by anxiety, fear, disgust, panic.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors

35. Sexual Deviance and Dysfunction
Female Sexual Arousal Disorder
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.

36. Sexual Deviance and Dysfunction
Male Erectile Disorder
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.

37. Sexual Deviance and Dysfunction
Female Orgasmic Disorder
Persistent or recurrent delay in, or absence of, orgasm following a normal excitement phase.
Women exhibit wide variability in the type or intensity of stimulation necessary to bring about orgasm and, therefore, the diagnosis should be based on clinical judgement about the woman’s general capacity for orgasm relative to her age, sexual experience and sexual interest etc.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.

38. Sexual Deviance and Dysfunction
Male Orgasmic Disorder
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity and duration.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.

39. Sexual Deviance and Dysfunction
Premature Ejaculation
Persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The clinician should take into account factors that affect the duration of the excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.

40. Sexual Deviance and Dysfunction
Dyspareunia
Recurrent or persistent genital pain associated with sexual intercourse in either a male or a female.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Most sufferers of Dyspareunia would seek treatment in a general medical setting, rather than a mental health clinic.

41. Sexual Deviance and Dysfunction
Vaginismus
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferers with sexual intercourse.
Can’t be better accounted for by an Axis 1 condition, or due to the effects of a medical condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Often associated with younger women, women who have negative attitudes about sex or who have been the victim of sexual abuse.

42. Sexual Deviance and Dysfunction
Sexual Dysfunction Due to a General Medical Condition
Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture.
There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by the direct physiological effects of a general medical condition.
Must not be better accounted for by an Axis 1 condition.
Can be specified as relating to the any of the above Sexual Disorders, e.g., Male Erectile Disorder due to Diabetes Mellitus. The medical condition should also be coded on Axis III.

43. Sexual Deviance and Dysfunction
Substance Induced Sexual Dysfunction
Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates the clinical picture.
There is evidence from the history, physical examination, or laboratory findings, that the sexual dysfunction is fully explained by substance abuse and is manifested by either:
Symptoms developed during, or within a month of, Substance Intoxication,
Medication use of etiologically related to the disturbance.

44. Sexual Deviance and Dysfunction
Cannot be accounted for by any other diagnoses.
Substance should be specified – e.g., cocaine, amphetamines, opioid etc…
Specifiers:
With impaired desire,
With impaired arousal,
With impaired orgasm,
With sexual pain,
With onset during intoxication.

45. Sexual Deviance and Dysfunction
Sexual dysfunction NOS
That is, everything else.

46. Sexual Deviance and Dysfunction
Some additional points re: sexual dysfunction:
1. There is an obvious overlap between many of the diagnoses and therefore clinical picture is unclear.
2. Prevalence – may be more common than sexual deviance with rates between 5% to 43% depending on nature of dysfunction.
3. More common in women than men – but are there reasons for this?

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4. Rates in women higher than for deviance.
5. Sexual dysfunction increases with age.
6. Years of education and marriage negatively correlated with sexual dysfunction.
7. Sexual dysfunction is commonly associated with medical problems and substances.

48. Sexual Deviance and Dysfunction
8. May be related to psychological concerns.
9. Psychosocial factors related to sexual dysfunction include:
Relationship problems,
Sociocultural standards about sex,
Religious views about sex,
Lack of education about sex,
Presence of significant stressors,
Traumas,
Extreme beliefs/standards,
Lack of communication.

49. Sexual Deviance and Dysfunction
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