14 Sexual Dysfunctions Gender Dysphoria and Paraphilic Disorders

14 Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

Human Sexual Response Cycle © Cengage Learning 2016

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 © Cengage Learning 2016

Lifetime Prevalence of Sexual Disorders in the United States (40– 80 Age Range) © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

Orgasmic Disorders • Female orgasmic disorder – 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 © Cengage Learning 2016

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 21 -33 percent of men © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

Multipath Model of Sexual Dysfunctions © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

Paraphilic Disorders © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 nonsexually aggressive men © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 20 s • Age range associated with sexual attractiveness – Most rapists name sexual motivation as primary reason for actions – Many rapists have multiple paraphilias © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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 © Cengage Learning 2016

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? © Cengage Learning 2016