PSCY Essay

Paraphilic Disorders, Sexual Dysfunctions, and Gender Dysphoria SSY 230: Lecture 11

What Patterns of Sexual Behavior Represent Psychological Disorders?

When it comes to sexuality, deciding which patterns of behavior represent psychological disorders becomes a complicated process, perhaps more so than in other areas of human behavior.

When we are evaluating the “normality” of a given sexual behavior, the context is extremely important, as are customs and mores, which change across cultures and over time. Attitudes and behaviors related to sexuality are continually evolving.

Perhaps because the topic has so many taboos, there was little scientific research on sexual disorders until relatively recently. The three individuals credited with paving the way for contemporary research on human sexuality are Alfred Kinsey, William Masters, and Virginia Johnson.

Paraphilic Disorders

The term paraphilia (para meaning “faulty” or “abnormal,” and philia meaning “attraction”) literally means a deviation from the norm in terms of the object of a person’s sexual attraction.

Paraphilias are behaviors in which an individual has recurrent, intense sexually arousing fantasies, sexual urges, or behaviors related to:

(1) nonhuman object,

(2) children or other nonconsenting persons, or

(3) the suffering or humiliation of self or partner

Clinicians diagnose paraphilic disorder when the paraphilia causes intense distress and impairment and has lasted for at least 6 months. The major categories of paraphilic disorders are listed in the following slide.

Paraphilic Disorders-Major Categories

Pedophilic Disorder

Sexual arousal from the presence of children or

adolescents

Exhibitionistic

Disorder

Sexual arousal from exposing the genitals to unsuspecting

stranger

Voyeuristic Disorder

Sexual pleasure from observing nudity or sexual activity of others

Fetishistic Disorder and Partialism

Sexual arousal from an object (fetishism) or from a part of the body (partialism)

Frotteuristic Disorder

Sexual urges about and sexually arousing fantasies of rubbing against or fondling a nonconsenting person

Sexual Masochism and Sexual Sadism Sexual arousal from being made to suffer

(masochism) or from inflicting suffering on another person

(sadism)

Transvestic Disorder

Cross-dressing

associated with intense distress or impairment

Paraphilic Disorders

A person’s nonnormative sexual behavior is not pathological in and of itself. The symptoms of a paraphilia must include fantasies, urges, or behaviors to bring about “recurrent and intense sexual arousal” that cannot be achieved in another fashion. Neither the DSM nor the ICD regard deviation from heterosexual intercourse as a criterion for a paraphilic disorder.

The essential feature of a paraphilic disorder, then, is that people with one of these disorders are so psychologically dependent on the particular form or target of their desire that they are otherwise unable to experience sexual arousal. Even if people with these disorders do not actually fulfill their urges or fantasies, they are obsessed with thoughts about acting upon them. Their attraction can become so strong and compelling that they lose sight of any goals other than achieving sexual fulfillment in this specific way. During periods in which the individual feels especially stressed, the symptoms may become more intense.

The life course of paraphilic disorders is that they begin in adolescence and tend to be chronic; however, the urge to commit acts that others consider sexually deviant may decline in later life. Paraphilic disorders also are more prevalent in men than women.

Having a paraphilic disorder is not illegal, but acting on paraphilic urges may be. As a result, the person who reports having such a disorder runs the risk of being arrested, convicted, and then required to register as a sex offender. Because people do not voluntarily report paraphilias to mental health care professionals, these disorders can be difficult to diagnose, and self-reports in surveys may actually prove to be more informative. Online reporting of paraphilias, in turn, produces more self-reports than do telephone surveys.

Pedophilic Disorder

People diagnosed with pedophilic disorder are sexually aroused by children or adolescents. Clinicians use this diagnosis for adults who are at least 18 years of age and at least 5 years older than the children to whom they are attracted.

The key feature of this disorder is that the individual experiences an intensity of sexual arousal when with children that may be equal to, if not greater than, that which he or she experiences with individuals who are physically mature. This diagnosis includes people who have acted upon their urges with children as well as those whose attraction is represented by viewing Internet pornography involving children but who do not act on those urges.

As mentioned, it is difficult to obtain prevalence data on paraphilic disorders, and particularly on pedophilic disorder given the illegality of the behavior. Perhaps the best estimate comes from a study in which researchers examined its prevalence through an online survey. If they could be assured of not getting caught, 6 percent of men and 2 percent of women stated that they would have sex with a child. The likelihood of these same individuals viewing Internet sex with children was somewhat higher, with 9 percent of men and 3 percent of women stating they would view child pornography.

For both men and women, interest in sex with children was associated with higher rates of antisocial or criminal behavior, as well as higher rates of abuse in childhood.

Exhibitionistic Disorder

People who engage in exhibitionism have fantasies, urges, and behaviors suggesting that they derive sexual arousal from exposing their genitals to an unsuspecting stranger.

In exhibitionistic disorder, these fantasies, urges, and behaviors cause significant distress or impairment. Exhibitionistic disorder begins early in adulthood and persists throughout life.

A number of studies were conducted which showed high rates of comorbidity with other psychiatric disorders including major depressive disorder and substance abuse.

The existence of comorbid conditions, along with the reluctance of people with the disorder to come forward, present numerous challenges both for developing an understanding of the causes of the disorder and for planning its treatment. The most important step in treatment is accurately assessing both the disorder itself and these comorbid conditions.

Voyeuristic Disorder

People who engage in voyeurism derive sexual pleasure from observing the nudity or sexual activity of others who are unaware of being watched.

Correspondingly, people with voyeuristic disorder are sexually aroused by observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity.

Voyeurism is related to exhibitionism and is the most common of the paraphilic disorders. People with either of these disorders are also likely to engage in sadomasochistic behaviors and cross-dressing.

Fetishistic Disorder and Partialism

People with fetishistic disorder are aroused by an object not specifically intended to be used in a sexual context. There is a wide range of objects to which people with fetishistic disorder can develop attachments. However, they do not include articles of clothing associated with cross-dressing or objects such as vibrators that people use in tactile genital stimulation.

In a related disorder, partialism, the individual is sexually aroused by the presence of a specific body part. Again, as with all paraphilic disorders, the attraction to objects or body parts must be recurrent, intense, and have lasted at least 6 months.

Frotteuristic Disorder

The person with frotteuristic disorder has recurrent, intense sexual urges and sexually arousing fantasies of rubbing against or fondling a nonconsenting person.

Among men diagnosed with paraphilic disorders, approximately 10 to 14 percent have committed acts of frotteurism.

Men with frotteuristic disorder seek out crowded places, such as a rush-hour subway train, where they can safely rub up against their unsuspecting victims, and public transportation does seem to be a major site at which this behavior takes place.

Victims report feeling violated and may go out of their way to avoid crowds, yet few if any file police reports.

Sexual Masochism and Sexual Sadism Disorders

The term masochism describes the act of seeking pleasure from being in pain. People with sexual masochism disorder are sexually aroused by being beaten, bound, or otherwise made to suffer. Conversely, people with sexual sadism disorder become sexually aroused by the physical or psychological suffering of another person. The DSM-5 does not classify the use of bondage, domination, and sadomasochism (BDSM) as a disorder in and of itself.

As is true for several of the paraphilic disorders, there is very little in the way of scientific research on sexual masochism and sexual sadism disorders. People with these disorders tend not to seek treatment because they feel no need to change, and because their behaviors often occur in the context of a consensual relationship. Even among consenting adults, acts of sexual masochism and sadism are shrouded in secrecy. Yet preference for BDSM activities remains relatively common.

Transvestic Disorder

Transvestism, also called “cross-dressing,” refers to the behavior of dressing in the clothing of the other sex. Men make up the large majority of individuals who show this behavior.

A clinician would diagnose an individual with transvestic disorder only if he showed the symptoms of a paraphilic disorder, namely distress or impairment. Psychologists would consider a man who frequently cross-dresses and derives sexual pleasure from this behavior as a transvestite, but they would not diagnose him with a disorder.

The DSM-IV-TR limited this behavior to heterosexual males, but DSM-5 opened the diagnosis to women or gay men who have this sexual interest.

Theories and Treatment of Paraphilic Disorders

As we mentioned at the outset, deciding what is normal in the area of sexuality is an issue fraught with difficulty and controversy. Critics argued against including several of the paraphilic disorders in DSM-5 because they felt that to do so pathologizes a sexual behavior that happens to be infrequent.

Moreover, they maintained that breaking the law is not a sufficient basis for determining that an individual engaging in a paraphilic behavior has a psychological disorder. This criticism is particularly leveled at the diagnoses of exhibitionistic, voyeuristic, and frotteuristic disorder, which don’t have victims in the same sense as do the other paraphilic disorders.

Researchers and advocates within the field of sexual sadism and sexual masochism were critical of including these disorders in DSM-5 at all, arguing that they do not share the qualities of the other paraphilic disorders because they are engaged in by consenting adults. The DSM authors, they believe, should base their decisions about psychiatric diagnoses on empirical evidence rather than on political or moral considerations. The present system, though imperfect, nevertheless satisfies some of its critics in that behaviors such as BDSM in and of themselves are not regarded as disorders.

Theories and Treatment of Paraphilic Disorders

To be sure, many challenges face researchers who attempt to understand the causes of a disorder that leads to so much damage and has so many legal ramifications. Apart from the difficulty of identifying people with the disorder, even those who are available for scrutiny by researchers may not represent the population from which they are drawn.

For example, most of the people we can study for disorders involving criminal acts such as pedophilic disorder are likely to have been arrested. Even in paraphilic disorders that do not involve a criminal offense, self-selection can determine who decides to participate in research. The problem of unrepresentative samples means that prevalence estimate data are likely to be biased and unreliable.

The main point to keep in mind is that by defining the disorders in this area as accompanying intense distress or impairment, authors of the DSM-5 hoped to avoid judging a behavior’s normality and instead to base the criteria for a disorder on an individual’s subjective experience of distress or degree of impairment in everyday life.

Biological Perspectives

Although it recognizes the role of psychological and sociocultural factors, the biological perspective emphasizes altered genetic, hormonal, and sensory factors in paraphilic disorders.

For men, the male sex hormone testosterone is the focus of theories and treatment, but dopamine and serotonin also play roles in male sexuality. Consequently, the World Federation of Societies of Biological Psychiatry advocates treatment of paraphilic disorders in men that includes SSRIs, antiandrogens, and luteinizing hormone-release hormone (LHRH), which acts as a suppressor in men for the production of testosterone.

Medications that stimulate LHRH receive support as effective treatments in reducing paraphilic symptoms in men. However, they carry the drawback that by reducing testosterone below the level achieved even by castration, they also decrease conventional nonparaphilic sexual activity and desire. Medications that target LHRH also result in a number of side effects such as loss of bone mineral content, cardiovascular disease, fatigue, sleep disorders, and hot flashes and therefore are not recommended for lifelong treatment.

Psychological Perspectives

Freud’s psychoanalytic understanding of the paraphilic disorders was the dominant psychological perspective throughout the twentieth century. According to Freud, these disorders were “perversions” representing both biological and psychological factors in early development.

The influential theorist John Money, in contrast, regarded paraphilias as the expressions of lovemaps—internal representations of an individual’s sexual fantasies and preferred practices. People form lovemaps in the late childhood years, when they first begin to discover and test ideas regarding sexuality. “Misprints” in this process can result in the establishment of sexual habits and practices that deviate from the norm. A paraphilia, according to this view, is due to a lovemap gone awry. The individual is, in a sense, programmed to act out fantasies that are socially unacceptable and potentially harmful.

The majority of the psychological literature on paraphilic disorders focuses on pedophilic disorder. A common theme in this literature is the idea of a “victim-to-abuser cycle” or “abused-abusers phenomena,” meaning that abusers were themselves abused at some point in their lives, probably when they were young. Arguing against these explanations is the fact that most abuse victims do not go on to abuse or molest children. On the other hand, some people with pedophilic disorder who were abused as children show an age preference that matches their age when they were abused, suggesting that they are replicating behaviors that were directed toward them as children.

Psychological Perspectives

Treatments within the psychological perspective seem most effective when combining individual with group therapy. In the group context, in particular, empathy training can help these individuals understand how their victims are feeling. Clinicians may also help clients learn how to control their sexual impulses. Relapse prevention, much as in treatment of addictive disorders, helps clients accept that even if they slip, this does not mean that they cannot overcome their disorder.

Clinicians no longer recommend a method used in the past known as aversion training, in which they teach clients to associate negative outcomes with sexual attraction toward children and use masturbatory reconditioning to change their orientation away from children.

Psychotherapy is the recommended treatment at the first level, particularly CBT. At increasing levels of severity, defined according to whether treatment is effective or not, clinicians add hormonal treatment starting with antiandrogens, progressing to progesterone, and finally neurohormones that act on the areas in the pituitary gland that control the release of sex hormones. At this point in treatment, appropriate only for the most severe cases, the goal is complete suppression of sexual desire and activity.

Another focus of treatment may be clinicians themselves. Due to stigmatization of people with these disorders, particularly pedophilic disorder, clinicians may be less willing to offer them treatment. In one intervention, researchers presented therapists in training with a 10-minute video that effectively challenged typical myths about pedophilia, such as the idea that it is a choice and that people with this disorder act upon their urges.

Sexual Dysfunctions

A sexual dysfunction is a marked divergence in an individual’s response in the sexual response cycle, along with feelings of significant distress or impairment.

To consider it a sexual dysfunction, clinicians must not be able to attribute this divergence to a psychological disorder, effects of a substance such as a drug of abuse or medication, or a general medical condition.

The DSM-5 differentiates between sexual dysfunctions that are lifelong and those that are acquired, as well as whether they are generalized or situational.

People with a lifelong sexual dysfunction experienced its symptoms continually since the time at which they became sexually active. By contrast, people with acquired sexual dysfunctions were asymptomatic prior to developing the symptoms.

Those dysfunctions that are situational occur with only certain types of sexual stimulation, situations, or partners. Generalized dysfunctions affect the individual in all sexual situations.

Sexual Response Cycle

Legendary researchers Masters and Johnson were the first scientists to systematically observe the sexual responses of men and women under controlled laboratory conditions. They identified four phases of the sexual response cycle—excitement (arousal), plateau, orgasm, and resolution.

During the excitement (or arousal) stage, the individual’s sexual interest heightens, and the body prepares for sexual intercourse (vaginal lubrication in the female, penile erection in the male). Sexual excitement continues to build during the plateau phase, and during the orgasm phase the individual experiences muscular contractions in the genital area that bring intense sensations of pleasure. The resolution phase is a period of return to a physiologically normal state. People differ in their typical patterns of sexual activity; some progress more readily through the phases and others at a slower pace. Not every sexual encounter necessarily includes all phases, however, and arousal and desire may occur

simultaneously with the processing of sexual stimuli.

Sexual Dysfunctions

Physiological factors and chronic health conditions are strongly related to the risk of developing sexual dysfunctions. These conditions can include diabetes, cardiovascular disease, other genitourinary diseases, psychological disorders, other chronic diseases, and smoking. In the case of some of these medical conditions, it is the medication and not the condition itself that places the individual at risk. For example, medications that treat high blood pressure can have the side effect of lowering sexual responsiveness in men.

Not surprisingly, perhaps, reliable prevalence data on these disorders are few. Definitions of many disorders have changed periodically, leading to differing estimates, and people are reluctant to report they are experiencing symptoms. Only recently have researchers begun to arrive at measurable criteria based on the unique assessment methods these disorders require. Fortunately, work toward the DSM-5 led to improved and more rigorous diagnostic procedures that eventually will lead to more reliable data sources.

In a research context, the Female Sexual Function Index is an empirical measure used in a number of studies to investigate the prevalence of sexual dysfunctions in women and to gauge the efficacy of treatment. The FSFI is a 19-item multidimensional self-report scale that asks questions related to sexual functioning within the past month, with subscales related to specific domains of lubrication, desire, subjective arousal, orgasm, satisfaction, and pain associated with intercourse. Another, more behaviorally oriented approach asks individuals to record sexual events on a daily basis in the form of a self-report diary.

Arousal DisordersPeople whose sexual disorders occur during the initial phases of

the sexual response cycle have low or no sexual desire or are

unable to achieve physiological arousal. As a result, they may

avoid having or be unable to have sexual intercourse.

Male Hypoactive Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder

The man with male hypoactive sexual desire disorder has an abnormally low level of sexual activity or may have no interest in sexual activity. In addition, a man with this disorder either has relatively few or no sexual fantasies.

A woman with female sexual interest/arousal disorder is interested in having intercourse, but her body does not physiologically respond during the arousal phase. The DSM-5 merged female hypoactive desire dysfunction and female

arousal dysfunction into a single syndrome called female sexual interest/arousal disorder because the two dysfunctions could not reliably be distinguished.

Arousal Disorders

Some reports indicate that low sexual desire is relatively prevalent among women, with estimates in some samples ranging as high as 55 percent, although the majority of studies from around the world place the prevalence at closer to 40 percent. In general, the percent of women who are distressed about having low sexual desire is far lower than is true for men. Therefore, if a sexual dysfunction were defined for women that was characterized by low levels of desire, it would apply to a large percentage of women, and not necessarily those who were truly distressed.

Because low sexual desire seems to be relatively common, the issue for diagnosing women is that loss of desire might not be the best or only criterion to use in deciding who has a sexual dysfunction. DSM-5 therefore defines this disorder as including loss of sexual interest across a range of behaviors instead of only loss of interest. The behaviors that suggest low sexual interest include lower levels of arousal, fewer erotic thoughts, less enjoyment of sexual activity, and less intense sensations during sexual activity.

Arousal Disorders

Erectile Disorder

Men with erectile disorder cannot attain or maintain an erection during sexual activity that is sufficient to allow them to initiate or maintain sexual activity. Even if they are able to achieve an erection, they are unable to penetrate or to experience pleasure during a sexual encounter.

Although once thought of as either physiologically or psychologically caused, erectile disorder is now understood as having multiple causes that cannot be clearly separated into these two categories. A very rough estimate of the prevalence of erectile disorder is 26 to 28 per 1,000 man-years, with higher rates among older men.

Disorders Involving Orgasm

Female Orgasmic Disorder

Inability to achieve orgasm, a distressing delay in achieving orgasm, or reduced intensity of orgasm constitutes female orgasmic disorder.

The factors relating to a woman’s reporting of female orgasmic disorder include stress, anxiety, depression, relationship satisfaction, and age-related changes in the genital area that can lead to pain, discomfort, irritation, or bleeding.

In general, women are more likely than men to report sexual difficulties involving the subjective quality of the experience. Men are more likely to report physical problems in achieving or maintaining an erection.

Disorders Involving Orgasm

Delayed Ejaculation and

Premature Ejaculation

Men who have a marked delay in ejaculation or who rarely if ever experience ejaculations have delayed ejaculation.

Men with premature (early) ejaculation reach orgasm in a sexual encounter with minimal sexual stimulation before, on, or shortly after penetration and before wishing to do so (within 1 minute).

Clinicians prefer to apply a psychiatric diagnosis only when the individual is distressed about the condition. The prevalence rate for premature ejaculation varies widely, from 8 to 30 percent, and seems to depend on age group and country.

The distinction between the nature of orgasmic difficulties for men and women led a group of clinicians and social scientists called the Working Group for a New View of Women’s Sexual Problems to criticize the DSM for failing to take into account the greater focus in women on relational aspects of sexuality and individual variations in women’s sexual experiences. They proposed that the profession define sexual problems as difficulties in any aspect of sexuality—emotional, physical, or relational.

Disorders Involving Pain

Clinicians diagnose sexual pain disorders characterized by the experience of difficulty in a sexual relationship due to painful sensations in the genitals from intercourse, genito-pelvic pain/penetration disorder.

Genito-pelvic pain/penetration disorder can affect both males and females. The individual experiences recurrent or persistent genital pain before, during, or after sexual intercourse.

Theories and Treatment of Sexual Dysfunction

Sexual dysfunctions represent an interaction of complex physiological, psychological, and sociocultural factors, and thus the biopsychosocial perspective is well suited to understand them.

To help a client with a sexual dysfunction, the clinician must first conduct a comprehensive assessment that includes a physical examination and psychological testing, including of the client’s partner if appropriate.

In addition, the clinician must assess the individual’s use of substances including not only drugs and alcohol, but also all medications, including psychotherapeutic ones.

Biological Perspectives

Perhaps one of the best-researched sexual dysfunctions is erectile disorder. In 1970, Masters and Johnson claimed that virtually all men (95 percent) with erectile disorder (ED) had psychological difficulties such as anxiety and job stress, boredom with long-term sexual partners, and other relationship issues. Since that time, researchers have arrived at very different conclusions as a result of new and more sophisticated assessment devices sensitive to the presence of physiological abnormalities.

Health care professionals now view more than half the cases of erectile disorder as attributable to physical problems of a vascular, neurological, or hormonal nature, or to impaired functioning caused by drugs, alcohol, and smoking. Thus, clinicians treating men with erectile disorder may first consider physiological contributions to the individual’s symptoms before concluding that psychological factors are the cause.

Medications to treat erectile disorder include the prescription drugs Viagra, Levitra, and Cialis. These are all in the category of phosphodiesterase (PDE) inhibitors, which work by increasing blood flow to the penis during sexual stimulation. What makes such medications appealing is the fact that they are so much less invasive than previous treatments for erectile disorder, such as surgery and implants, and so much less awkward than vacuum pumps or penile injections. These medications work when accompanied by the experience of sexual excitement, unlike other treatments in which the man achieves an erection artificially and independent of what is going on sexually with the man or his partner.

Biological Perspectives

Treatment of female sexual interest/arousal disorder that follows from the biological perspective incorporates hormonal replacement therapy (estrogen and progesterone), estrogen cream applied directly to the vagina, and testosterone therapy. Doctors may also give women a PDE inhibitor (“female Viagra”), but its efficacy remains undemonstrated. This drug is not to be confused with flibanserin, approved by the FDA in 2015 under the trade name Addyi. Though also dubbed the “female Viagra,” Addyi actually works by a different

mechanism than PDE inhibitors and is meant to increase a woman’s interest in sexual activity. Data on its efficacy suggest that flibanserin may have beneficial effects, though more research is needed .

Genito-pelvic pain/penetration disorder presents a different set of challenges. From a biological perspective, the physical symptoms can come from a variety of sources, including disturbances in the muscle fibers in the pelvic area (called the “pelvic floor”). When treating these disorders, however, the clinician may be unable to trace the exact cause of the individual’s pain. The best approach appears to be multifaceted, including application of corticosteroids and physical therapy to promote muscle relaxation and improved blood circulation. The clinician may also use electrical nerve stimulation to relieve the individual’s pain and prescribe pharmacological agents such as amitriptyline and pregabalin (Lyrica®) .

Psychological Perspectives

While recognizing the role of physiological factors, the psychological perspective emphasizes the further contributing effects, if not the causal role, of cognitions, emotions, and attitudes toward sexuality.

Learned associations between sexual stimuli and pleasurable feelings can play an important role in sexual excitability. In the case of erectile disorder, one team of researchers identified as a predisposing factor a man’s belief in the “macho myth” of sexual infallibility. Belief in this myth makes males more prone to developing dysfunctional thoughts (such as, “I’m incompetent”) when they have an unsuccessful sexual experience. Once the man activates these thoughts, they impair his ability to process erotic stimuli and have sexual thoughts and images. By turning his attentional focus away from the encounter and toward his feelings of incompetence and sadness, they make him less able to achieve and maintain an erection during future sexual encounters .

Researchers have also identified a man’s self-image about the size of his genitals as a factor in erectile dysfunction. Among a sample of military men aged 40 and under, those with lower genital self-image had higher rates of sexual anxiety, which in turn was related to higher rates of erectile dysfunction.

For women, preoccupation with body image is known to interfere with sexual functioning, perhaps interacting with attitudes toward sexuality in general.

In addition to discomfort with their bodies, individuals may hold negative “sexual self-schemas” such as feeling unloved, inadequate, and unworthy. They then transfer these self-schemas onto sexual situations, causing them to become anxious when they feel that an inability to achieve an orgasm will make their partner become tired. This belief in their own incompetence in sexual situations understandably inhibits their enjoyment.

The quality of the relationship may also contribute to sexual dysfunction, particularly for women, whose sexual desire is sensitive to interpersonal factors including the frequency of positive interactions . Researchers have also identified the cognitive factors relevant in genito-pelvic pain/penetration disorder that compound the physical causes, making women with this disorder highly sensitized even to words related to sex.

Psychological Perspective

The core treatment of sexual dysfunctions involving disturbances of arousal and orgasm follows from the principles that Masters and Johnson established, namely treating both partners in a couple, reducing anxiety about sexual performance, and developing specific skills such as sensate focus, in which the interaction is intended to lead not to orgasm but to the experience of pleasurable sensations during the phases prior to orgasm. This procedure reduces the couple’s anxiety levels until eventually they are able to focus not on their feelings of inadequacy but instead on the sexual encounter itself. Clinicians may also teach the partners to masturbate or to incorporate methods of sexual stimulation other than intercourse, such as clitoral stimulation alone.

Expanding on these methods, therapists rely upon principles derived from cognitive-behavioral therapy that focus on the individual’s thoughts that can inhibit sexual arousal and desire. As we saw earlier, distorted body image and negative sexual self-concept can interfere with sexual satisfaction. Restructuring those cognitions could therefore help alleviate sexual dysfunction symptoms. Furthermore, helping clients understand that each sexual encounter does not need to be perfect but can be “good enough” can help couples focus on sexual pleasure rather than on performance.

Clinicians often involve the client’s partner, encouraging both people to communicate more effectively and to have more positive intimate experiences.. For sexual pain disorders, cognitive-behavioral therapy alone does not seem to be effective, but it is most beneficial when integrated with muscle relaxation, biofeedback, and education. Women can learn to train or retrain their pelvic muscles to reduce painful muscle contractions during intercourse as well as to decrease their anxiety levels and self-consciousness.

Gender Dysphoria

We turn now to disorders in which individuals experience distress from perceiving a mismatch between their biological sex, the sex determined by their chromosomes, and their inner sense of gender, called gender identity. In the DSM-5, the term gender dysphoria refers to distress that may accompany the incongruence between a person’s experienced or expressed gender and that person’s assigned gender.

Not everyone experiences distress as the result of this incongruence, but many are distressed if they are unable to receive treatment through hormones and/or surgery. In the current criteria for disorder, the individual experiences identification with the other sex. The feeling of being “in the wrong body” causes feelings of discomfort and a sense of inappropriateness about the person’s assigned gender. Both these conditions must be present for a clinician to assign the diagnosis. Thus, the clinical problem is the dysphoria, not the individual’s gender identity.

Another term that relates to cross-gender identification is transsexualism, which also describes the inner feeling of belonging to the other sex (individuals who experience this may be referred to as “trans”). The term is generally considered equivalent to transgender identity.

Some people with gender dysphoria wish to live as members of the other sex, and they act and dress accordingly. Unlike individuals with transvestic disorder, these people do not derive sexual gratification from cross-dressing. Further, many other identities fall in the category of transgender, including gender nonconforming, nonbinary, and agender. These terms correspond with the notion that not all transgender people see themselves as the opposite gender. Instead they might not feel they belong to any particular gender.

Gender Dysphoria

The DSM-5 authors presented a strong case for using the term gender dysphoria to replace gender identity disorder, with the specification whether the individual is a child or post-adolescent. One reason for this proposed change was to take away the stigma attached to the label of cross-gender identification as a “disorder.” Thus, having cross-gender identification does not necessarily imply that an individual is distressed or has a disorder. Only if that person feels dysphoria about having the sexual makeup with which he or she was born can a diagnosis be applied. Moreover, although some groups would advocate for the notion of removing gender dysphoria entirely from the diagnostic nomenclature, to do so could preclude individuals who wish to seek gender-affirming surgery from insurance coverage because there would be no diagnosis for the clinician to give.

Some individuals with gender dysphoria may choose to pursue gender-affirming medical procedures. These range from taking hormones to a variety of surgical procedures such as facial feminization surgery, chest reconstructive surgery (“top” surgery), and genital reconstructive surgery (“bottom” surgery). Each of these procedures requires psychological and other evaluations to ensure that the individual does not have any mental health conditions that might affect judgment or decision making and does have documented and persistent gender dysphoria.

Theories and Treatment of Gender Dysphoria

Clinicians who work with transgender individuals experiencing gender dysphoria can provide support through psychotherapy and help clients decide whether they want to seek out other options such as hormone therapy or gender-affirming surgery. The American Psychological Association’s Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (TGNP) suggest that clients achieve the most positive outcomes when they receive social support or trans-affirmative care and are seen from an interdisciplinary perspective, and seek to prepare their trainees in psychology to work with clients who identify as TGNP.

According to the World Professional Association for Transgender Health (WPATH), clinicians ideally provide an assessment of a client’s well-being, without regard to diagnostic criteria, in determining whether a particular client is able to exercise good judgment and decision making around pursuing medical treatments. In this way, clinicians can be seen in a gatekeeper role, in which their determination can affect a client’s ability to pursue gender-affirming treatments.

Theories and Treatment of Gender Dysphoria

Given that clinicians will continue to treat individuals with gender dysphoria, new approaches are emerging based on transgender theory that emphasize a more fluid view of gender than the binary male-female dichotomy, a perspective also articulated in the APA TGNP Guidelines. Clinicians can begin by using the gender terminology the client prefers. Rather than assume that people’s motivations, behaviors, and attitudes are based on their socially defined identities, clinicians can also recognize that these categories are conditional. For example, they can avoid using terms like real or biological gender. Through this approach, often referred to as affirmative psychotherapy, clinicians can provide education about medical options and help transgender clients safely explore their gender identity and connect with sources of social support.

Even though transgender identity itself is depathologized in DSM-5, clients will nevertheless continue to face transphobia, the negative stereotyping and fear of transgender individuals. Providing transgender individuals with social support may also improve their feelings of well-being.

Rather than recommending gender reassignment surgery to help clients cope with social pressures to conform to one gender or another, clinicians can instead let their clients define their own gender identities. Through this process, transgender individuals can explore more openly and without bias their multiple, intersecting identities.

Activity prompt:

Think about how diagnoses change over time (ex. gender identity disorder to gender dysphoria) and how that is impacted by societal perceptions and political changes. What current diagnoses, if any, can you imagine being phased out/adjusted in the years to come? Why? If none, explain why not.

Paraphilic

Disorders, Sexual Dysfunctions, and Gender Dysphoria:

The Biopsychosocial Perspective

The sexual disorders constitute three discrete sets of difficulties in aspects of sexual functioning and behavior.

Although many unanswered questions remain about their causes, we need a biopsychosocial perspective to understand how individuals acquire and maintain these diverse problems over time.

Moreover, researchers and clinicians are increasingly developing models that incorporate integrated treatment.

The growing research base the DSM-5 authors used reflects not only expansion of the empirical approaches to sexual disorders but also the adoption of a broader, more inclusive, and socioculturally sensitive approach to understanding and treatment.

Source

Images 1,2, and 4:

https://venngage.com/gallery/post/not-just-a-mans-world-sexual-dysfunction-among-women-and-what-to-do-about-it /

Image 3 https://www.treated.com/erectile-dysfunction/psychological-causes-of-ed

Image 5: http://www.imop.gr/en/node/2475

Text: Whitbourne, Susan Krauss. Abnormal Psychology: Clinical Perspectives on Psychological Disorders. McGraw-Hill Higher Education.