Sexual Disorders and Gender Identity Disorder

Sexual Disorders and Gender Identity Disorder
Chapter 13

Sexual behavior is a major focus of both our private thoughts and public discussions Experts recognize two general categories of sexual disorders: Sexual dysfunctions – problems with sexual responses Paraphilias – repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations Comer, Abnormal Psychology, 7e

DSM-IV-TR also includes a diagnosis of gender identity disorder, a sex-related pattern in which people feel that they have been assigned to the wrong sex Relatively little is known about racial and other cultural differences in sexuality Sex therapists and sex researchers have only recently begun to attend systematically to the importance of culture and race Comer, Abnormal Psychology, 7e

Comer, Abnormal Psychology, 7e
Sexual Dysfunctions Sexual dysfunctions are disorders in which people cannot respond normally in key areas of sexual functioning As many as 31% of men and 43% of women in the U.S. suffer from such a dysfunction during their lives Sexual dysfunctions are typically very distressing, and often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems Often these dysfunctions are interrelated; many patients with one dysfunction experience another as well Comer, Abnormal Psychology, 7e

Sexual Dysfunctions The human sexual response can be described as a cycle with four phases: Desire Excitement Orgasm Resolution Sexual dysfunctions affect one or more of the first three phases Comer, Abnormal Psychology, 7e

Sexual Dysfunctions Some people struggle with sexual dysfunction their whole lives (labeled “lifelong type” in DSM-IV-TR) For others, normal sexual functioning preceded the disorder (labeled “acquired type”) In some cases the dysfunction is present during all sexual situations (labeled “generalized type”) In others it is tied to particular situations (labeled “situational type”) Comer, Abnormal Psychology, 7e

Disorders of Desire Desire phase of the sexual response cycle Consists of an urge to have sex, sexual fantasies, and sexual attraction to others Two dysfunctions affect this phase: Hypoactive sexual desire disorder Sexual aversion disorder Comer, Abnormal Psychology, 7e

Disorders of Desire Hypoactive sexual desire disorder Characterized by a lack of interest in sex and little sexual activity Physical responses may be normal Prevalent in about 16% of men and 33% of women DSM-IV-TR refers to “deficient” sexual interest/activity but provides no definition of “deficient” In reality, this criterion is difficult to define Comer, Abnormal Psychology, 7e

Disorders of Desire Sexual aversion disorder Characterized by a total aversion to (disgust of) sex Sexual advances may sicken, repulse, or frighten This disorder seems to be rare in men and more common in women Comer, Abnormal Psychology, 7e

Disorders of Desire A person’s sex drive is determined by a combination of biological, psychological, and sociocultural factors, and any of these may reduce sexual desire Most cases of low sexual desire or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly Comer, Abnormal Psychology, 7e

Disorders of Desire Biological causes A number of hormones interact to produce sexual desire and behavior Abnormalities in their activity can lower sex drive These hormones include prolactin, testosterone, and estrogen for both men and women Sex drive can also be lowered by chronic illness, some medications (including birth control pills), some psychotropic drugs, and a number of illegal drugs Comer, Abnormal Psychology, 7e

Disorders of Desire Psychological causes A general increase in anxiety, depression, or anger may reduce sexual desire in both women and men Fears, attitudes, and memories may contribute to sexual dysfunction Certain psychological disorders, including depression and obsessive-compulsive disorder, may lead to sexual desire disorders Comer, Abnormal Psychology, 7e

Disorders of Desire Sociocultural causes Attitudes, fears, and psychological disorders that contribute to sexual desire disorders occur within a social context Many sufferers of desire disorders are feeling situational pressures Examples: divorce, death, job stress, infertility, and/or relationship difficulties Cultural standards can impact the development of these disorders The trauma of sexual molestation or assault is also likely to produce sexual dysfunction Comer, Abnormal Psychology, 7e

Disorders of Excitement
Excitement phase of the sexual response cycle Marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing In men: erection of the penis In women: swelling of the clitoris and labia and vaginal lubrication Two dysfunctions affect this phase: Female sexual arousal disorder (formerly “frigidity”) Male erectile disorder (formerly “impotence”) Comer, Abnormal Psychology, 7e

Female sexual arousal disorder Characterized by repeated inability to maintain proper lubrication or genital swelling during sexual activity Many with this disorder also have desire or orgasmic disorders It is estimated that more than 10% of women experience this disorder Because this disorder is so often tied to an orgasmic disorder, researchers usually study the two together; causes of the two disorders will be examined together Comer, Abnormal Psychology, 7e

Male erectile disorder (ED) Characterized by repeated inability to attain or maintain an adequate erection during sexual activity An estimated 10% of men experience this disorder According to surveys, half of all adult men have erectile difficulty during intercourse at least some of the time Comer, Abnormal Psychology, 7e

Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes Even minor physical impairment of the erection response may make a man vulnerable to the effects of psychosocial factors Comer, Abnormal Psychology, 7e

Biological causes The same hormonal imbalances that can cause hypoactive sexual desire can also produce ED Most commonly, vascular problems are involved ED can also be caused by damage to the nervous system from various diseases, disorders, or injuries The use of certain medications and substances may interfere with erections Comer, Abnormal Psychology, 7e

Biological causes Medical devices have been developed for diagnosing biological causes of ED One strategy involves measuring nocturnal penile tumescence (NPT) Men typically have erections during REM sleep; abnormal or absent nighttime erections usually indicate a physical basis for erectile failure Comer, Abnormal Psychology, 7e

Psychological causes Any of the psychological causes of hypoactive sexual desire can also interfere with arousal and lead to erectile dysfunction For example, as many as 90% of men with severe depression experience some degree of ED One well-supported cognitive explanation for ED emphasizes performance anxiety and the spectator role Once a man begins to have erectile difficulties, he becomes fearful and worried during sexual encounters; instead of being a participant, he becomes a spectator and judge This can create a vicious cycle of sexual dysfunction where the original cause of the erectile failure becomes less important than the fear of failure Comer, Abnormal Psychology, 7e

Sociocultural causes Each of the sociocultural factors tied to hypoactive sexual desire has also been linked to ED Job and marital distress are particularly relevant Comer, Abnormal Psychology, 7e

Disorders of Orgasm Orgasm phase of the sexual response cycle Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically For men: semen is ejaculated For women: the outer third of the vaginal walls contract There are three disorders of this phase: Rapid or Premature ejaculation Male orgasmic disorder Female orgasmic disorder Comer, Abnormal Psychology, 7e

Disorders of Orgasm Rapid or Premature ejaculation Characterized by persistent reaching of orgasm and ejaculation with little sexual stimulation About 30% of men experience rapid ejaculation at some time Psychological, particularly behavioral, explanations of this disorder have received more research support than other explanations The dysfunction seems to be typical of young, sexually inexperienced men It may also be related to anxiety, hurried masturbation experiences, or poor recognition of arousal Comer, Abnormal Psychology, 7e

Disorders of Orgasm Rapid or Premature ejaculation There is a growing belief among many clinical theorists that biological factors may also play a key role in many cases of this disorder One theory states that some men are born with a genetic predisposition A second theory argues that the brains of men with rapid ejaculation contain certain serotonin receptors that are overactive and others that are underactive A third explanation holds that men with this dysfunction experience greater sensitivity or nerve conduction in the area of their penis Comer, Abnormal Psychology, 7e

Disorders of Orgasm Male orgasmic disorder Characterized by a repeated inability to reach orgasm or by a very delayed orgasm after normal sexual excitement Occurs in 8% of the male population Biological causes include low testosterone, neurological disease, and head or spinal cord injury Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the central nervous system (CNS), can also affect ejaculation Comer, Abnormal Psychology, 7e

Disorders of Orgasm Male orgasmic disorder A leading psychological cause appears to be performance anxiety and the spectator role, the cognitive factors involved in ED Comer, Abnormal Psychology, 7e

Disorders of Orgasm Female orgasmic disorder Characterized by persistent delay in or absence of orgasm following normal sexual excitement Almost 25% of women appear to have this problem 10% or more have never reached orgasm An additional 10% reach orgasm only rarely Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly Female orgasmic disorder is more common in single women than in married or cohabiting women Comer, Abnormal Psychology, 7e

Disorders of Orgasm Female orgasmic disorder Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning Early psychoanalytic theory used to consider lack of orgasm during intercourse to be pathological Typically linked to female sexual arousal disorder The two disorders tend to be studied and treated together Once again, biological, psychological, and sociocultural factors may combine to produce these disorders Comer, Abnormal Psychology, 7e

Disorders of Orgasm Female orgasmic disorder Biological causes A variety of physiological conditions can affect a woman’s arousal and orgasm These conditions include diabetes and multiple sclerosis The same medications and illegal substances that affect erection in men can affect arousal and orgasm in women Postmenopausal changes may also be responsible Comer, Abnormal Psychology, 7e

Disorders of Orgasm Female orgasmic disorder Psychological causes The psychological causes of hypoactive sexual desire and sexual aversion, including depression, may also lead to female arousal and orgasmic disorders Memories of childhood trauma and relationship distress may also be related Comer, Abnormal Psychology, 7e

Disorders of Orgasm Female orgasmic disorder Sociocultural causes For decades, the leading sociocultural theory of female sexual dysfunction was that it resulted from sexually restrictive cultural messages This theory has been challenged because: Sexually restrictive histories are equally common in women with and without disorders Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant Comer, Abnormal Psychology, 7e

Disorders of Orgasm Female orgasmic disorder Sociocultural causes Researchers suggest that unusually stressful events, traumas, or relationships may produce the fears, memories, and attitudes that characterize these dysfunctions Research has also linked certain qualities in a woman’s intimate relationships (such as emotional intimacy) to orgasmic behavior Comer, Abnormal Psychology, 7e

Disorders of Sexual Pain
Two sexual dysfunctions do not fit neatly into a specific phase of the sexual response cycle These are the sexual pain disorders: Vaginismus Dyspareunia Comer, Abnormal Psychology, 7e

Vaginismus Characterized by involuntary contractions of the muscles of the outer third of the vagina Severe cases can prevent a woman from having intercourse Perhaps 20% of women occasionally have pain during intercourse, but less than 1% of all women have vaginismus Comer, Abnormal Psychology, 7e

Vaginismus Most clinicians agree with the cognitive-behavioral theory that vaginismus is a learned fear response A variety of factors can set the stage for this fear, including anxiety and ignorance about intercourse, trauma caused by an unskilled partner, and childhood sexual abuse Some women experience painful intercourse because of infection or disease, leading to “rational” vaginismus Most women with vaginismus also have other sexual disorders Comer, Abnormal Psychology, 7e

Dyspareunia Characterized by severe pain in the genitals during sexual activity As almost 14% of women and about 3% of men Dyspareunia in women usually has a physical cause, most commonly from injury sustained in childbirth Although relationship problems or psychological trauma from abuse may contribute to dyspareunia, psychosocial factors alone are rarely responsible Comer, Abnormal Psychology, 7e

Treatments for Sexual Dysfunctions
The last 35 years have brought major changes in the treatment of sexual dysfunction Early 20th century: psychodynamic therapy Believed that sexual dysfunction was caused by a failure to negotiate the stages of psychosexual development Therapy focused on gaining insight and making broad personality changes; was generally unhelpful Comer, Abnormal Psychology, 7e

1950s and 1960s: behavioral therapy Behavioral therapists attempted to reduce fear by applying relaxation training and systematic desensitization Had moderate success, but failed to work in cases where the key problems included misinformation, negative attitudes, and lack of effective sexual techniques Comer, Abnormal Psychology, 7e

1970: Human Sexual Inadequacy This book, written by William Masters and Virginia Johnson, revolutionized treatment of sexual dysfunctions This original “sex therapy” program has evolved into a complex, multidimensional approach Includes techniques from cognitive, behavioral, couples, and family systems therapies, along with a number of sex-specific techniques More recently, biological interventions have also been incorporated Comer, Abnormal Psychology, 7e

What Are the General Features of Sex Therapy?
Modern sex therapy is short-term and instructive Therapy typically lasts 15 to 20 sessions It is centered on specific sexual problems rather than on broad personality issues Comer, Abnormal Psychology, 7e

What Are the General Features of Sex Therapy?
Modern sex therapy includes: Assessing and conceptualizing the problem Assigning “mutual responsibility” for the problem Education about sexuality Attitude change Elimination of performance anxiety and the spectator role Increasing sexual and general communication skills Changing destructive lifestyles and marital interactions Addressing physical and medical factors Comer, Abnormal Psychology, 7e

What Techniques Are Applied to Particular Dysfunctions?
In addition to the universal components of sex therapy, specific techniques can help in each of the sexual dysfunctions Comer, Abnormal Psychology, 7e

Hypoactive sexual desire and sexual aversion These disorders are among the most difficult to treat because of the many issues that feed into them Therapists typically apply a combination of techniques, which may include: Affectual awareness, self-instruction training, behavioral techniques, insight-oriented exercises, and biological interventions such as hormone treatments Comer, Abnormal Psychology, 7e

Erectile disorder Treatments for ED focus on reducing a man’s performance anxiety and/or increasing his stimulation May include sensate-focus exercises such as the “tease technique” Comer, Abnormal Psychology, 7e

Erectile disorder Biological approaches, used when the ED has biological causes, have gained great momentum with the development of sildenafil (Viagra) and other erectile dysfunction drugs Most other biological approaches have been around for decades and include gels, suppositories, penile injections, and a vacuum erection device (VED) These procedures are now viewed as “second-line” treatment Another biological approach – penile implant surgery – is performed only rarely Comer, Abnormal Psychology, 7e

Male orgasmic disorder Like treatment for ED, therapies for this disorder include techniques to reduce performance anxiety and increase stimulation When the cause of the disorder is physical, treatment may include a drug to increase arousal of the sympathetic nervous system Comer, Abnormal Psychology, 7e

Rapid or Premature ejaculation Premature ejaculation has been successfully treated for years by behavioral procedures such as the “stop-start” or “pause” procedure and the “squeeze” technique Some clinicians favor the use of fluoxetine (Prozac) and other serotonin-enhancing antidepressant drugs Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation Many studies have reported positive results with this approach Comer, Abnormal Psychology, 7e

Female arousal and orgasmic disorders Specific treatments for these disorders include cognitive-behavioral techniques, self-exploration, enhancement of body awareness, and directed masturbation training Biological treatments, including hormone therapy or the use of sildenafil (Viagra), have also been tried, but research has not found such interventions to be consistently helpful Comer, Abnormal Psychology, 7e

Female arousal and orgasmic disorders Again, a lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and is orgasmic through other means For this reason, some therapists believe that the wisest course of action is simply to educate women whose only concern is lack of orgasm through intercourse Comer, Abnormal Psychology, 7e

Vaginismus Specific treatment for vaginismus takes two approaches: Practice tightening and releasing the muscles of the vagina to gain more voluntary control Overcome fear of intercourse through gradual behavioral exposure treatment Most women treated for vaginismus using these methods eventually report pain-free intercourse Comer, Abnormal Psychology, 7e

Dyspareunia Determining the specific cause of dyspareunia is the first stage of treatment Given that most cases are caused by physical problems, medical intervention may be necessary Comer, Abnormal Psychology, 7e

What Are the Current Trends in Sex Therapy?
Over the past 30 years, sex therapists have moved beyond the approach first developed by Masters and Johnson Therapists now treat unmarried couples, those with other psychological disorders, couples with severe marital discord, the elderly, the medically ill, the physically handicapped, clients with a homosexual orientation, and clients with no long-term sex partner Comer, Abnormal Psychology, 7e

What Are the Current Trends in Sex Therapy?
Therapists are paying more attention to excessive sexuality, which is sometimes called hypersexuality or sexual addiction The use of medications to treat sexual dysfunction is troubling to many therapists They are concerned that therapists will choose biological interventions rather than a more integrated approach Comer, Abnormal Psychology, 7e

Paraphilias These disorders are characterized by unusual fantasies and sexual urges or behaviors that are recurrent and sexually arousing Often involve: Nonhumans Children Nonconsenting adults Humiliation of self or partner Comer, Abnormal Psychology, 7e

Paraphilias According to the DSM-IV-TR, paraphilias should be diagnosed only when the urges, fantasies, or behaviors last at least 6 months For most paraphilias, the urges, fantasies, or behaviors must also cause great distress or impairment For certain paraphilias, however, performance of the behavior itself is indicative of a disorder, even if the individual experiences no distress or impairment Example: sexual contact with children Comer, Abnormal Psychology, 7e

Paraphilias Some people with one kind of paraphilia display others as well Relatively few people receive a formal diagnosis, but clinicians believe that the patterns may be quite common Comer, Abnormal Psychology, 7e

Paraphilias Some experts argue that, with the exception of nonconsensual paraphilias, paraphilic activities should be considered a disorder only when they are the exclusive or preferred means of achieving sexual excitement and orgasm Comer, Abnormal Psychology, 7e

Paraphilias Although theorists have proposed various explanations for paraphilias, there is little formal evidence to support the theories None of the treatments applied to paraphilias have received much research or been proved clearly effective Psychological and sociocultural treatments have been available the longest, but today’s professionals are also using biological interventions Comer, Abnormal Psychology, 7e

Fetishism The key features of fetishism are recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object, often to the exclusion of all other stimuli The disorder usually begins in adolescence Almost anything can be a fetish Women’s underwear, shoes, and boots are especially common Comer, Abnormal Psychology, 7e

Fetishism Researchers have been unable to pinpoint the causes of fetishism Psychodynamic theorists view fetishes as defense mechanisms, but therapy using this model has been unsuccessful Comer, Abnormal Psychology, 7e

Fetishism Behaviorists propose that fetishes are learned through classical conditioning Fetishes are sometimes treated with aversion therapy, covert sensitization, or imaginal exposure Another behavioral treatment is masturbatory satiation, in which clients masturbate to boredom while imagining the fetish object An additional behavioral treatment is orgasmic reorientation, a process which teaches individuals to respond to more appropriate sources of sexual stimulation Comer, Abnormal Psychology, 7e

Transvestic Fetishism
Also known as transvestism or cross-dressing Characterized by fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal Comer, Abnormal Psychology, 7e

Transvestic Fetishism
The typical person with transvestism is a heterosexual male who began cross-dressing in childhood or adolescence Transvestism is often confused with gender identity disorder (transsexualism), but the two are separate patterns The development of the disorder seems to follow the behavioral principles of operant conditioning Comer, Abnormal Psychology, 7e

Exhibitionism Characterized by arousal from the exposure of genitals in a public setting Also known as “flashing” Sexual contact is neither initiated nor desired Usually begins before age 18 and is most common in males Treatment generally includes aversion therapy and masturbatory satiation May be combined with orgasmic reorientation, social skills training, or cognitive-behavioral therapy Comer, Abnormal Psychology, 7e

Voyeurism Characterized by repeated and intense sexual desires to observe people as they undress or to spy on couples having intercourse; may involve acting upon these desires The person may masturbate during the act of observing or while remembering it later The risk of discovery often adds to the excitement Comer, Abnormal Psychology, 7e

Voyeurism Many psychodynamic theorists propose that voyeurs are seeking power Others have explained it as an attempt to reduce fears of castration Behaviorists explain voyeurism as a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene Comer, Abnormal Psychology, 7e

Frotteurism A person who develops frotteurism has recurrent and intense fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person Almost always male, the person fantasizes during the act that he is having a caring relationship with the victim Usually begins in the teen years or earlier Acts generally decrease and disappear after age 25 Comer, Abnormal Psychology, 7e

Pedophilia Characterized by fantasies, urges, or behaviors involving sexual activity with a prepubescent child, usually 13 years of age or younger Some people are satisfied with child pornography Others are driven to watching, fondling, or engaging in sexual intercourse with children Evidence suggests that two-thirds of victims are female Comer, Abnormal Psychology, 7e

Pedophilia People with pedophilia develop the disorder in adolescence Some were sexually abused as children Many were neglected, excessively punished, or deprived of close relationships in childhood Most are immature, display distorted thinking, and have an additional psychological disorder Some theorists have proposed a related biochemical or brain structure abnormality but clear biological factors have yet to emerge in research Comer, Abnormal Psychology, 7e

Pedophilia Most people with pedophilia are imprisoned or forced into treatment Treatments include aversion therapy, masturbatory satiation, orgasmic reorientation, and treatment with antiandrogen drugs Cognitive-behavioral treatment involves relapse-prevention training, modeled after programs used for substance dependence Comer, Abnormal Psychology, 7e

Sexual Masochism Characterized by fantasies, urges, or behaviors involving the act or the thought of being humiliated, beaten, bound, or otherwise made to suffer Most masochistic fantasies begin in childhood and seem to develop through the behavioral process of classical conditioning Comer, Abnormal Psychology, 7e

Sexual Sadism A person with sexual sadism finds fantasies, urges, or behaviors involving the thought or act of psychological or physical suffering of a victim sexually exciting Named for the infamous Marquis de Sade People with sexual sadism imagine that they have total control over a sexual victim Comer, Abnormal Psychology, 7e

Sexual Sadism Sadistic fantasies may first appear in childhood Pattern is long-term Appears to be related to classical conditioning and/or modeling Psychodynamic and cognitive theorists view people with sexual sadism as having underlying feelings of sexual inadequacy Comer, Abnormal Psychology, 7e

Sexual Sadism Biological studies have found possible abnormalities in the endocrine system The primary treatment for this disorder is aversion therapy Comer, Abnormal Psychology, 7e

A Word of Caution The definitions of paraphilias, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur Some clinicians argue that, except when people are hurt by them, paraphilic behaviors should not be considered disorders at all Comer, Abnormal Psychology, 7e

Gender Identity Disorder
The DSM-IV-TR categorization of this disorder has become controversial in recent years Many people believe that transgender experiences reflect alternative – not pathological – ways of experiencing one’s gender identity Others argue that gender identity disorder is, in fact, a medical problem that may produce personal unhappiness Comer, Abnormal Psychology, 7e

According to current DSM-IV-TR criteria, people with this disorder persistently feel that they have been assigned to the wrong biological sex They would like to remove their primary and secondary sex characteristics and acquire the characteristics of the opposite sex Comer, Abnormal Psychology, 7e

Men with gender identity disorder outnumber women 2 to 1 People with gender identity disorder often experience anxiety or depression and may have thoughts of suicide Comer, Abnormal Psychology, 7e

The disorder sometimes emerges in childhood and disappears with adolescence In some cases it develops into adult gender identity disorder Various theories have been proposed to explain this disorder, but research is limited and generally weak Some clinicians suspect biological – perhaps genetic or prenatal – factors Abnormalities in the hypothalamus (particularly the bed nucleus of stria terminalis) are a potential link Comer, Abnormal Psychology, 7e

To more effectively assess and treat those with the disorder, clinical theorists have tried to distinguish the most common patterns of gender dysphoria: Female-to-male Male-to-female: Androphilic Type Male-to-female: Autogyneophilic Type Some adults with this disorder change their sexual characteristics by way of hormones; others opt for sexual reassignment (sex change) surgery Comer, Abnormal Psychology, 7e

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