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12 Paraphilic Disorders, Sexual Dysfunctions, and Gender Dysphoria

Chapter Objectives

After reading this chapter, you should be able to do the following:

• Identify sexual behavior that is considered to be disordered.

• Name the various types of sexual dysfunctions.

• Explain how people with sexual dysfunctions can be helped.

• Explain how or if sexual dysfunctions can be prevented.

• Describe the etiology and treatment of gender dysphoria.

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Although sex is healthy, important, and worth discussing, it is not always a topic that is talked about openly. However, what to do, how to do it, and who to do it with are the central top- ics of movies, books, television shows, magazine articles, newspaper reports, popular music, Internet sites, and advertisements. Despite this avalanche of information, society’s attitudes toward sex remain conflicted and confused. Are some sex practices signs of mental illness? What is normal, anyway?

Because of people’s seemingly endless fascination with the topic, sex is the subject of a huge amount of professional literature. This chapter focuses on three aspects of this literature: paraphilic disor- ders, sexual dysfunctions, and gender dysphoria, as described in the DSM–5. The chapter is divided into three main sections. The first deals with the para- philias (unusual sexual desires or acts), the second examines sexual dysfunction (difficulties in per- forming sexual acts), and the third section discusses gender dysphoria (discomfort with one’s assigned sex role).

Although the focus of the chapter is on sexual behavior, it is wrong to think about these prob- lems as somehow separable from other aspects of a person’s life. As you will see, an individual’s sexual behavior is influenced by his or her genetic back- ground, medical condition, personal history, use of substances, psychological state (especially the pres- ence of anxiety or depression), and the prevailing cultural norms. To show how these factors come together to influence both normal and problematic sexual behavior, this chapter tells the story of four

people: Peter Hall, Anne Lawrence, and Anne’s two sons, Jared and Luke. Through a series of tragic circumstances, the lives of these four people intersected and were changed forever. We will begin with the case of Peter Hall.

Ray Fisher/Getty Hugh Hefner, the publisher of Playboy magazine (shown here in his earlier years), has been a recognizable symbol of sexual identity in Western culture.

The Case of Peter Hall: Part 1

Peter Hall was born with a silver spoon in his mouth. His successful stockbroker father sent him to elite private schools, and his mother made sure that he received the best music lessons. Each summer, he went on trips to the cultural capitals of Europe. Now in his late 40s, Peter speaks five languages, drives a Jaguar sports car, and owns a yacht and three homes. He is a familiar figure at art galleries and chairs the museum board. Charming and urbane, Peter is especially well known for his charity work with underprivileged boys. Not only does he sponsor sports teams and camps, but he has also looked after wayward youths. He has provided them with emotional and financial support; some have even lived in one of his homes. So, imagine the shock to the community when Peter was arrested and charged with child sexual assault. The following document displays a newspaper account of the case against Hall.

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Newspaper Story Describing the Arrest of Peter Hall Chair of Museum Board Arrested for Child Sexual Assault

by Ron Nicks

Businessman Peter Hall, aged 48, was arrested by Metro Police and charged with seven counts of child sexual assault. Hall had been under investigation since police were approached by Mrs. Anne Lawrence, a divorced schoolteacher from Ross River. She claimed that Hall had sexually abused her sons, Jared, now aged 13, and Luke, aged 10, and that the abuse had gone on for a year.

“At first, I thought Peter was the best thing that ever happened to my boys. Their father abandoned us, and I had to raise them alone. They needed a father figure, and I thought Peter was it.”

According to their mother, Jared and Luke met Hall last summer at the beach. They were admiring Hall’s classic antique surfboard when he struck up a conversation with the boys. Later that afternoon, he invited Anne and her sons to his beachfront apartment for refreshments. In the apartment, the boys played with Hall’s vast collection of video games and listened to his music CDs. They made plans to get together again the next day. After the summer, their relationship continued. On the weekends that Hall used the beachfront apartment, the boys were invited to join him. Often, their mother accompanied them.

“I went to his apartment many times,” says Anne. “I always found Peter pleasant and entertaining. He was so refined and cultured. I thought we were friends. Jared and Luke adored Peter, and he treated them like the sons he never had. He introduced them to opera and classical music. I thought he was the ideal father.”

Anne first began to suspect something was wrong when she found drugs (later identified as amphetamines) in Jared’s drawer. She went to Hall for help. He offered to pay for counseling and to enroll Jared in a special program for substance using teenagers. Because the program was located near his city home, Hall offered to have Jared live with him. What Hall neglected to tell Anne was that he was the source of Jared’s amphetamines. Jared moved in with Hall, and Anne visited him on many weekends. Instead of improving with treatment, however, Jared seemed to get worse. According to Anne, he often seemed “dazed and strung out.”

“One night I got a call from Peter telling me that Jared was ‘very sick.’ I hurried to Hall’s home. I knew something was seriously wrong when I saw the police car parked outside. I ran inside. There was Jared, just lying there, unconscious from what turned out to be an overdose of sleeping pills. We got him to the hospital and had his stomach pumped. When he awoke, he told me that he had tried to kill himself to get away from Peter, who not only used him for sex but also made him have sex with Peter’s friends.”

Anne soon learned that Jared was not Hall’s only victim; Luke had also been involved. The police investigation turned up five other boys who claimed that they, too, had been Hall’s victims. Police inspector Philip Langton, who led the investigation, searched Hall’s home after the arrest. “We found amphetamines and hundreds of photographs of naked boys, some as young as 5 years old. There were many computer games, toys, and videos—everything young boys might like. Hall’s home computer was full of photos of boys, as well as contacts and connections to pedophile sites around the world.”

Hall faces trial next March.

See appendix for full case study.

The Case of Peter Hall: Part 1 (continued)

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Section 12.1 Paraphilic Disorders (Paraphilias)

12.1 Paraphilic Disorders (Paraphilias) A breakthrough in research on sex occurred in the 1940s when Alfred Kinsey (1894–1956) and his col- leagues used surveys to paint a statistical portrait of the sexual behavior of 18,000 American men and women (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). Many of their findings were surprising, at least at the time. Prac- tices that were considered rare and harmful (mas- turbation, for instance) were actually found to be quite common. Since then, we have come to recog- nize that what constitutes acceptable sexual behav- ior is largely a function of cultural mores. Activities considered normal in one time and place may be prohibited in another (Giami, 2015). Nevertheless, independent of time and culture, we have been able to determine certain sexual behaviors that qualify as psychological disorders.

According to the DSM–5, the paraphilic disorders are characterized by intense sexual fantasies about, and urges to have (a) sex with nonhuman objects (bras or panties, for example), (b) sex that involves suffering on the part of oneself or one’s partner, or (c) sex with children. The person need not act out these fantasies to receive the diagnosis, although many do (American Psychiatric Association [APA], 2013). Although the DSM–5 describes only a small number of paraphilias, it contains an “unspecified” category that may include dozens, per- haps hundreds, more (Schewe, 1997). It seems that just about anything, from scuba diving suits to toilet seats, can become imbued with erotic significance. Despite their diverse range, all paraphilias share a central characteristic—in every case, sexual behavior has been discon- nected from a loving, consensual relationship with another adult. This category would be used, for example, in situations in which the clinician is confident that a paraphilia is present and causes distress or impairment (recall the maladaptive behavioral perspective discussed in Chapter 1), but there is insufficient diagnostic information present to determine the type of paraphilia (Krueger & Kaplan, 2015).

Almost all people with paraphilias are male (Handy & Meston, 2016; Konrad, Welke, & Opitz- Welke, 2015). Here is one possible explanation: Males may be more aware of their sexual arousal because they experience erections and have noticeable changes, whereas women may be aroused but may not report it because they experience sexuality differently and without obvious physical changes like an erection (Handy & Meston, 2016; Konrad, Welke, & Opitz-Welke, 2015). Another possible explanation is that women might not be attending to their genital responses and/or might be unable to accurately perceive their genital responses, thus lacking interoceptive aware- ness when genital arousal occurs (Handy & Meston, 2016). Regardless, some researchers believe that the reason(s) behind the significant gender split remain unknown (Konrad et al., 2015). It is unusual for a female to meet the diagnostic criteria for any of the paraphilias other than masoch- ism (for which they still represent the minority; APA, 2013).

Bettman/Getty The work of Alfred Kinsey during the 1940s challenged commonly held ideas about American sexual behavior.

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Diagnosis The main characteristics of the DSM–5 paraphilic disorders are summarized in this section. To qualify for one of these diagnoses, a person must have fantasies and urges that last at least six months. During this period, people need not restrict themselves solely to paraphilic fantasies or sex; they can engage in other types of sexual behavior as well. In most cases, however, paraphilias (more often, several paraphilias) become the person’s dominant form of sexual expression. Like compulsions, paraphilic disorders consume much of people’s lives (Guay, 2009). Individuals may engage in their paraphilia every day, sometimes several times each day. Some collect fetishistic objects (for example, shoes or bras) or photographs depict- ing their preferred paraphilic interest. Although some paraphiliacs are loners who keep their sexual behavior hidden, others are social enough to join interest groups of fellow paraphiliacs who meet either in person or on the Internet. They may share paraphilic objects or informa- tion, and, in some notorious cases of pedophilia, they may even share victims.

Exhibitionist Disorder The DSM–5 defines exhibitionist disorder as exposing one’s genitals to a stranger, sometimes accompanied by masturbation (APA, 2013). The desire to expose one’s genitals in public is often seen as a compulsive behavior. Affected individu- als (“flashers”) may be trying to shock the observer, and they often succeed. In some cases, exhibition- ism may involve the fantasy that the stranger will find the display sexually arousing. The disorder is usually found among teenage and young adult males who grew up in sexually repressive homes and have little experience with women.

Fetishistic Disorder The use of nonliving objects, such as shoes, bras, underpants, or leather clothing, in fantasy or directly to achieve sexual gratification, is called fetishistic disorder or, more commonly, fetishism. Some individuals have extensive fetish collections that they have purchased or, in some cases, stolen. They may masturbate while fondling the object, or they may ask their partners to don the object dur- ing sex. The fetishistic object is not just a stimulant

(many men are attracted by women in high heels and sheer stockings); it is detached from the female and sexually stimulating on its own. For people with fetishism, sex is impossible without the fetish. Using objects specifically designed for sexual stimulation (vibrators, for example) is not considered a sign of fetishism. Fetishism begins in puberty and tends to last a lifetime (APA, 2013).

Photodisc/Thinkstock Exhibitionism, or exposing one’s geni- tals to a stranger, is the most common sexual offense punishable by law.

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Section 12.1 Paraphilic Disorders (Paraphilias)

Frotteuristic Disorders Frottage is French for “rub,” and frotteuristic disorder involves touching or rubbing up against nonconsenting individuals, usually in crowded places. Typically, the individual gets behind a person in a crowd and rubs his or her genitals against the person’s buttocks or fondles the person with his or her hands. This behavior may be accompanied by fantasies of a sexual relationship with the individual. Most perpetrators run away as soon as the victim reacts. The behavior is most common in males aged 15–25 (APA, 2013).

Pedophilic Disorder (Pedophilia) Fantasizing about or engaging in sex with prepu- bescent children is termed pedophilic disorder or, more commonly, pedophilia. According to the DSM–5, pedophiles must be at least five years older than their victims (APA, 2013). Pedophiles, who seem to be exclusively male, generally focus on children younger than age 13. Most pedophiles pre- fer females, but some prefer males, and others are aroused by both (Hughes, 2007). Pedophiles may be sexually attracted only to children (exclusive type) or to both children and adults (nonexclusive type). Most are satisfied to fantasize about sex with chil- dren or to collect child pornography. Because this subgroup of pedophiles never acts out their fanta- sies, they typically do not get into trouble with the law (possession or distribution of child pornogra- phy is a crime, however). Among pedophiles who do engage in sex with children, some fondle them or masturbate in front of them. Others engage in sexual intercourse with children, sometimes using force to achieve their ends.

Pedophiles rationalize their behavior as “educat- ing” the child or giving the child sexual pleasure, or they allege that the child seduced them. Pedophiles may limit their activities to their own children (incest) or to others they know, or they may prey on strangers (Choi, Choo, Choi, & Woo, 2015). In gen- eral, pedophiles will usually prey on children they know, and within a short distance of where the pedophile lives. This may include extended family members who live nearby (Krueger & Kaplan, 2008). Some seek occupations (such as teaching) that bring them into contact with children. Pedophiles may physically threaten their victims to prevent disclosure, as well as provide gifts (toys, access to adult-themed video games like Call of Duty, and so on) to keep the child quiet, as well as to coerce the child to participate in the abusive situation. Pedophilic disorder usually begins in puberty and is highly resistant to punishment or treatment. (See Part 2 of Peter Hall’s case in the appendix.)

Alexander Koerner/Getty In 1977, French-Polish film director Roman Polanski was arrested and charged with unlawful sexual inter- course with a minor, then 13-year-old Samantha Geimer.

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Section 12.1 Paraphilic Disorders (Paraphilias)

Sexual Sadism Disorder

Fantasizing about inflicting or actually inflicting suf- fering or humiliation on another for sexual satisfac- tion is called sexual sadism disorder (APA, 2013). The term sadism is derived from the name of the Marquis de Sade (1740–1814), who wrote about his need to inflict humiliation and pain on others. Sadistic behaviors include whipping, torturing, cut- ting, beating, pinching, and spanking. Some people with sexual sadism find masochistic partners; oth- ers impose their desires on unwilling partners. Sex- ual sadism inflicted on nonconsenting partners is a criminal offense. The severity of sadistic acts tends to increase over time and, when associated with antisocial personality disorder, may lead to rape or even murder (Chan & Beauregard, 2016). Serial “lust murders,” in which men rape, often mutilate, and then deliberately kill their female victims, may be an extreme form of sexual sadism. Note, however, that neither rape nor murder is a paraphilia. Both seem motivated as much by hate and aggression as by lust, as the accompanying Highlight makes clear regarding rape.

Pantheon/Superstock The Marquis de Sade, namesake of the term sadism, had written extensively of his need to inflict pain and humiliation on others.

Highlight: Rape Is Not Sex

The previous definition of rape included only penile/vaginal penetration achieved against a person’s will by menace or force, or when the victim cannot give consent (because of intellectual disability, illness, intoxication, or being unconscious or comatose). Early in 2012 the Federal Bureau of Investigation (FBI) changed the definition to make the term more inclusive and more accurate. Most important, the phrase “carnal knowledge of a female forcibly and against her will” was removed. Now males and females can be victims or perpetrators. The new definition states, in part:

The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim . . . . The revised definition includes any gender of victim or perpetrator, and includes instances in which the victim is incapable of giving consent because of temporary or permanent mental or physical incapacity, including due to the influence of drugs or alcohol or because of age. The ability of the victim to give consent must be determined in accordance with state statute. Physical resistance from the victim is not required to demonstrate lack of consent. (FBI, 2012, p. 1)

Rape should be differentiated from sex with a minor, which is sometimes called statutory rape. Sex with a minor is always a crime, even when both parties consent to the sex.

(continued)

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Sexual Masochism Disorder Sex involving real or imagined humiliation and suffering inflicted upon the self is described as sexual masochism disorder (APA, 2013). Females may fantasize about being held down and raped, for example. Males may stick themselves with pins or give themselves electric shocks while masturbating. When partners are involved, masochistic acts include whipping, bondage, and being urinated on. Some couples carry out elaborate sex rituals involving fetish- istic objects, such as leather-studded belts. Most of the time, physical damage is avoided, but, in some cases, masochists’ desire to feel pain can lead to serious injury or even death. For instance, some people may deprive themselves of oxygen by hanging from a noose or putting a plastic bag over their heads (hypoxyphilia or asphyxiophilia). The goal is to achieve enough oxygen depletion to enhance sexual arousal (Coluccia et al., 2016).

The accompanying Highlight addresses the question of whether sexual sadism and sexual masochism should be considered DSM–5 disorders.

Because many rapes are not reported, it is difficult to know how often rape occurs, but we do know that it is fairly common. In addition to any physical injury they suffer, rape victims may feel vulnerable, guilty, and depressed. The aftereffects of rape may include a negative attitude toward sex, an anxiety disorder, substance abuse, or all three. In addition, victims whose cases come to trial must endure humiliating questioning from defense lawyers, who attempt to demonstrate that the victim somehow provoked the attack (Campbell, 1998). Considerable psychological and community support is expended each year helping rape victims to reestablish their lives (Sacco, 2014).

Even though nonconsenting sex is a criterion for the paraphilic disorders (APA, 2013), rape is not considered a paraphilia because it is not primarily a sexual act. Although rape involves sexual penetration, rapists may not have erections or reach orgasm during their attack. They seem to be motivated not by sex but by the need to dominate, degrade, and subjugate their victims (Jamel, 2014). This is why rapes often include sadistic acts. Victims have had their breasts burned with cigarettes, their genitals mutilated, and, in extreme cases, they have been murdered.

According to one study, prevalence rates coming out of studies on university campuses range from 6% to 41% of college students being victims of attempted or completed rape (Jordan, 2014). When looking only at sexual assault, a more recent study found that prevalence rates of sexual assault were about 23% among first-year students (Conley et al., 2017). Regardless of the statistics, any percentage is too high.

What should you do if you or someone you know is a victim of rape? Most universities and colleges have a counseling center and/or a crisis hotline where you can report rape, either as a victim yourself or if a friend is a victim. In addition, you can visit http://rapecrisis.com/, a comprehensive website that also lists a 24-hour hotline: 210-349-7273. The website also has an online feature through which you can talk to counselors.

The Violence Against Women Act was reauthorized in 2013. It mandates services for all victims of domestic violence, sexual assault, dating violence and stalking, including but not limited to Native women, immigrants, LGBT victims, college students and youth, and public housing residents (Sacco, 2014). This is an important piece of legislation as it states that violence against any woman is considered a crime, no matter her race or ethnic background.

Highlight: Rape Is Not Sex (continued)

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Transvestic Disorder Cross-dressing for sexual pleasure by heterosexual males is called transvestic disorder (Balon, 2016). Most often, transvestic fetishists masturbate while wearing women’s clothes. Individuals may begin by wearing one article of women’s clothing, usually underwear, and stop there. Alternatively, they may progress to wearing an entire outfit and makeup. The behavior usually begins in childhood or adolescence and continues through adulthood and even through marriage. Cross-dressing by gay males (drag queens) to entertain an audience is not an example of transvestic fetishism. Some individuals find cross-dressing calming, even when no sex is involved. They may seek to live as women and may even have their sex surgi- cally reassigned. In general, however, cross-dressing by males who believe they are really females is not a form of fetishism but rather indicates gender dysphoria (discussed later in this chapter).

Voyeuristic Disorder Sexual fulfillment and excitement gained by watching unsuspecting people disrobe or engage in sex is called voyeuristic disorder. Watching people who know they are being observed is not considered a paraphilia (APA, 2013). Usually, men masturbate while “peeping” or later as they recall what they have seen. In severe cases, this is the person’s only form of sex. It begins

Highlight: Should Sexual Sadism and Sexual Masochism Disorder Be DSM–5 Diagnostic Categories?

We have spent the entire length of the book discussing mental disorders, and how to define abnormal behavior. There is one area that remains quite controversial: Are we as psychologists, and students, able to state with conviction that sexual sadism disorder and sexual masochism disorder are diagnosable? This question has led to much debate in the field, and outside of it. For example, Handy and Meston (2016) note that paraphilic fantasies are common in college-age students as well as in the general population. This is especially true for sadism and masochism or, to use as the authors’ term, BDSM (standing for “bondage & discipline/dominance & submission/sado-masochism”). Handy and Meston found that more than 60% of male college students fantasized about sadism and bondage, while more than 50% of female college students reported having had sexual fantasies in which they submitted to force or intrusive thoughts about being sexually victimized. It seems that what we are diagnosing appears to be occurring in the statistical majority of the population, which contradicts the statistical frequency definition of abnormal behavior.

An opposing viewpoint is posited by Konrad, Welke, and Opitz-Welke (2015), who note that in an empirical analysis conducted by Robertson and Knight (2015), it was discovered that sadism and psychopathy consistently predicted sexual and nonsexual violence. In addition, serial sex offenders were more likely to engage in sexual masochism (Konrad et al., 2015).

Not surprisingly, we are presenting to you opposing perspectives. Suppose a patient came to you asking for help to “get over” his love of being a sexual masochist. How would you handle this? Would you diagnose him with sexual masochism disorder? Are we discussing paraphilias, lifestyle choices, sexual preferences, or something else? These are just a few more questions for you to think about.

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in late adolescence; it cannot be diagnosed before age 18, since the DSM–5 states that there is “substantial difficulty in differentiating it from age-appropriate puberty-related sexual curi- osity and activity” (APA, 2013, p. 688). The course of the disorder varies based on the age of the individual (APA, 2013).

Unspecified Paraphilic Disorder The DSM–5 category of unspecified paraphilic disorder encompasses a mixed collection of sex- ual behaviors and interests including making obscene phone calls; having sex with corpses or animals; deriving sexual pleasure from enemas; and partialism, which is an intense sexual attraction to a specific body part, most often breasts or buttocks.

It is difficult to know how frequently paraphilias occur because people with paraphilic dis- orders rarely seek clinical assistance (Burgan, 2010). The limited data that are available as to prevalence come mainly from surveys of people who have been convicted of sex crimes— which is hardly a representative sample of the general population. Convicted sex criminals are not even a representative sample of people with paraphilias because most paraphilias are not illegal.

Another reason it is difficult to obtain accurate prevalence estimates is that paraphilic behav- ior may be masked by other diagnoses. For example, some people engage in paraphilic behav- ior only when intoxicated by alcohol or drugs, whereas others display paraphilic behavior only during psychotic episodes. These individuals will normally be diagnosed with substance intoxication or psychosis, respectively; their paraphilic behavior may never be officially recorded. Although it may be a difficult clinical judgment to make, people who deliberately use substances to help them act out their paraphilic fantasies should probably be diagnosed as having a paraphilic disorder because it is their primary disorder.

Etiology

Biological Causes Research on the biological causes of the paraphilias has concentrated on trying to find some physiological or anatomical difference between people with paraphilias and everyone else. Because sex drive is determined partly by hormone levels, and because paraphilias affect mainly men, researchers have tried to demonstrate that men with paraphilias have higher levels of male sex hormones than people without paraphilias. Similarly, because brain dam- age can lead to odd sexual behavior in animals, scientists have tried to find evidence that peo- ple with paraphilias have brain damage. Although both lines of investigation have produced some confirmatory evidence (Holoyda & Kellaher, 2016; Mohnke et al., 2014), the data are far from conclusive. One problem is that hormone levels are not tied directly to paraphilias. Most men with high hormone levels do not meet the diagnostic criteria for a paraphilia. A second problem is that hormone levels are affected by various substances. Because people with para- philic disorders, especially those convicted of sex crimes, may also use substances, it is not clear whether higher than normal hormone levels are the cause of paraphilias or the result of substance abuse (Langevin, 1992).

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Because paraphilias are largely a male phenomenon and some types seem to run in fam- ilies, researchers have suggested that they may be at least partly inherited. Keep in mind, though, that a trait does not have to be genetic to run in families. It is possible that members of each new generation are introduced to paraphilic behavior by their forebears. Pedophilia, for example, may be the result of one generation molesting the next (Zucker & Seto, 2015). In sum, it has not yet proved possible to identify a specific biological cause for any of the para- philias. Progress is likely to remain slow because research volunteers are rare, and, conse- quently, sample sizes are small. The same problems apply to research on the potential social and psychological etiologies of the paraphilias.

Social and Psychological Causes Because sexual behavior usually takes two people, it is a social process. You must first locate a potential partner, ascertain whether your desire is reciprocated, and then initiate the behav- iors that eventually lead to sex. In the paraphilic disorders, one or more of these preliminaries has somehow gone awry—those with a paraphilic disorder were thought to have a kind of “courtship disorder” (Freund & Seto, 1998). However, the “courtship theory” postulated by Freund and Seto (1998) is not supported by current data. Although the theory may sound rea- sonable, it does not offer etiological explanations for voyeuristic disorder, exhibitionist disor- der, frotteuristic disorder, and preferential rape (this means forcible sex agreed upon before- hand by both participants). That is, distortions of the normal courtship process in males is not a supported explanation for paraphilic disorders (Balon, 2013).

How do paraphilias evolve? The answer probably depends on the specific paraphilia and the specific person (Laws & O’Donohue, 1997). There appear to be common factors that apply to practically all paraphilias, however, and these are just what you might expect (Furnham & Haraldsen, 1998). Specifically, people with paraphilias seem to have had childhood and adolescent experiences that limited their ability to be aroused by consensual sexual activ- ity, increased their arousal by atypical stimuli, or restricted their ability to empathize with the victims of their paraphilic behavior. For example, some people with paraphilias were led to consider themselves unattractive, a feeling that produced severe social anxiety. Instead of dating and courtship, they turned to less socially threatening forms of sexual fulfillment, such as the paraphilias. Some people with paraphilias come from environments that fostered repressive, guilt-producing attitudes toward sex. There is also evidence that some people with paraphilias were sexually abused as children (Levenson & Grady, 2016; Thibaut et al., 2016). Their early experiences may have limited their ability to form intimate relationships later in life.

The psychological results of these early experiences—social anxiety, ignorance, guilt, fear (alone or in combination)—serve to misdirect sexual impulses away from intimate social rela- tionships and toward other sexual outlets. Once this happens, practically anything can take on sexual connotations (Love, 1993). Articles of women’s clothing, for example, can become fetishistic objects through classical conditioning. That is, they are conditioned stimuli whose presence during masturbation leads to their association with the conditioned response of orgasm (Sarver & Gros, 2014; Thibaut et al., 2016).

Paraphilic learning can also take place through operant conditioning. For example, when they were children, people with transvestic disorder may have been encouraged and rewarded for

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dressing as females. Modeling may also play a role in the development of paraphilias. Para- philic activity is common in pornography, and people without other sexual outlets may copy the behavior depicted in DVDs, online, and in magazines. Once tried, this behavior may be reinforced by masturbation and orgasm. However, some research suggests that conditioning is unlikely to play a significant role in the onset of paraphilic disorders (Zucker & Seto, 2015). What do you think?

In contrast to behavioral theories about the etiology of paraphilias, psychodynamic expla- nations focus on the apparent symbolism of these disorders. For example, men who don women’s clothing may be seeking a way out of their responsibilities (as fathers or providers). Similarly, people who seek physical punishment and humiliation during sex may be display- ing guilt about their sexual urges, whereas those who find administering punishment sexually exciting may be overcoming feelings of inadequacy by seeking power over others.

Although they are difficult to prove, these psychodynamic hypotheses seem at least superfi- cially plausible, and they do not exclude the possibility that paraphilic behavior is learned. A complete explanation for paraphilias may need to include both conditioning and psychody- namic components. Because most people with a paraphilic disorder are men, biological fac- tors will need to be incorporated as well. Finally, as already noted, substance use may provide the disinhibition that allows people to act on their paraphilic urges. In other words, like most disorders, the paraphilias will almost certainly turn out to be the result of social, psychologi- cal, and biological factors. (See Part 3 of Peter Hall’s case in the appendix.)

Treatment Clinical psychologists have always considered the paraphilias difficult to treat (Konrad, Welke, & Opitz-Welke, 2015). This is not surprising given that most people who undergo treatment are convicted sex offenders—men with the most severe, and most antisocial, paraphilias. People with mild paraphilias are rarely detected, let alone treated. Felons who participate in treatment are usually motivated by the promise of early release from jail, or they attend treatment after release as a parole requirement. Few are intrinsically motivated to change. Some, like Peter Hall, may not even admit that their behavior is disordered or harmful to oth- ers. Most treatment research has been aimed at “difficult to treat” sex criminal paraphiliacs, especially people with pedophilic disorder (see Balon, 2013, for example).

Even when clients are motivated to change, psychological treatments may not be up to the task (Walton & Chou, 2015). Psychodynamic therapy, based on insight and interpretation, has not been successful at “curing” paraphilias, nor has the most commonly applied form of behavior therapy—aversive conditioning. The idea behind aversive conditioning is to asso- ciate paraphilic objects with negative stimuli, thereby transforming their sexually arousing properties into aversive ones (Sarver & Gros, 2014). For example, to treat a person with a fetish for women’s shoes, therapists pair a painful stimulus, such as an electric shock, with one of the fetishist’s favorite shoes. Eventually, instead of sexual arousal, the sight of the shoe should elicit fear. Treating a pedophile is similar; an aversive stimulus is administered while the client looks at a photograph of a child (Zucker et al., 2015).

Because aversive conditioning is designed to be unpleasant (that is why it is called aver- sive), treatment dropouts are common. To make aversive conditioning more palatable, some

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therapists have used covert sensitization, in which aversive stimuli are presented, not directly (as in electric shock), but in the imagination (Walton & Chou, 2015). For example, a client may be asked to imagine approaching a child and then, as the client becomes aroused, to conjure up an image of being caught in a sexual act with the child by disgusted relatives. Unfortunately, neither aversive conditioning nor covert sensitization, on their own, produces a significant reduction in paraphilic behavior.

In an attempt to improve treatment outcomes, clinicians have devised cognitive-behavioral (multimodal) treatment programs (Calleja, 2013). In addition to aversive conditioning, these treatments may include cognitive restructuring, desensitization (to overcome the anxiety produced by social and sexual situations), stress management, and skills training designed to help clients develop social relationships.

In cases of incest, family therapy may be employed to help family members come to grips with the perpetrator’s behavior. Relapse prevention may be used to help people recognize and avoid situations most likely to stimulate their paraphilic behavior (Calleja, 2013; Walton & Chou, 2015).

There is evidence that cognitive-behavioral treatment reduces the likelihood that paraphilic behavior will be repeated (Sarver & Gros, 2014), but relapses still occur, especially among pedophiles with a long history of sex offenses and whose victims are boys rather than girls. Because of the relatively high likelihood of relapse, certain treatment options might appear to be rather drastic to some people. Chemical castration with drugs is one such treatment option for repeat sex offenders (Konrad, Welke, & Opitz-Welke, 2015). For example, they may be given Depo-Provera (medroxyprogesterone), a birth control drug that reduces the level of the male sex hormone testosterone (Assumpção, Garcia, Garcia, Bradford, & Thibaut, 2014). Lowering testosterone levels reduces sex drive and makes erections more difficult to achieve. In some cases, antidepressants, antipsychotics, and tranquilizers can have similar effects (Assumpção et al., 2014). Because the drugs simply lower sex drive while leaving sexual inter- ests unchanged, clients are likely to return to their paraphilic behaviors once these drugs are discontinued. For this reason, drugs should be supplemented with psychological treatment.

The balancing argument given to justify such severe treatment is the even greater harm suf- fered by the victims of sex offenders, especially children. Victims of sex crimes may develop anxiety disorders (including posttraumatic stress disorder) and depression. Some may turn to abusing substances for solace. Many will develop some type of sexual problem themselves. Proponents argue that by preventing sex crimes, sexual predator laws (despite their stigmatiz- ing brutality) produce more good than harm. (See Part 4 of Peter Hall’s case in the appendix.)

Prevention Because treatment is difficult and relapse a significant problem, many experts believe that prevention, especially of sex crimes, is the best way to use our scarce economic and health resources (Daro, 1994; Reppucci, Land, & Haugaard, 1998). Primary prevention efforts have so far been limited to censoring paraphilic pornography. The idea is that pornographic mate- rials may have two negative effects: (a) They may provoke naive viewers into modeling unac- ceptable behaviors that, if reinforced through orgasm, may lead to the development of sexual disorders, and (b) they may stimulate people who already have antisocial sexual fantasies

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to act them out (Lasher & Stinson, 2017). In a society that values freedom of speech, a complete ban on pornography is impossible to achieve. About the best we can hope for is to keep pornography away from minors. Additionally, it is unclear whether pornogra- phy has as strong an effect on antisocial sex- ual behavior as many people believe (Lasher & Stinson, 2017). For both reasons, banning pornography has received less attention from psychological researchers than have various forms of secondary prevention. Recent research has outlined, however, one example of a successful primary prevention program: Prevention Project Dunkelfeld, which targets potential offenders. This pro- gram was established in Germany in 2005 to provide free and confidential treatment for individuals with pedophilic disorder who wanted therapeutic help. One service offered by this program is an anonymous hotline num- ber to call in case they feel they may commit a pedophilic act (Levine & Dandamudi, 2016). Would this program work as well in the United States? Can we presume that a treatment pro- gram that works well in another country would work as well, or better, in the United States?

One approach to secondary prevention uses school programs and public service announce- ments to warn children of potential dangers and to encourage them to report suspicious people or incidents (Lasher & Stinson, 2017; Levine & Dandamudi, 2016). A more extreme approach to secondary prevention is to keep sexual offenders locked away so that they can- not offend again. Several states have “sexual predator” laws that permit the legal authorities to conduct civil commitment proceedings for about-to-be-released prisoners deemed likely to repeat a sex offense. The outcome of these proceedings can be indefinite involuntary incar- ceration in a mental hospital (Grudzinskas & Henry, 1997). Theoretically, people who have served their complete prison terms may remain in custody indefinitely. In practice, this rarely happens; most offenders are released eventually. To limit their opportunity to repeat their crimes and to allow members of the community to protect themselves and their children, many jurisdictions require police to register sex offenders and to inform community mem- bers when a registered sex offender moves into their neighborhood (Lasher & Stinson, 2017).

12.2 Sexual Dysfunctions The chapter on sexual dysfunctions is new to the DSM–5. In the DSM–IV–TR, sexual dysfunc- tions were included in the chapter on sexual and gender identity disorders. Sexual dysfunc- tions interfere with an individual’s ability to perform sexual acts. As are most of the disorders described in this book, sexual dysfunctions are mainly exaggerations of common problems. At one time or another, practically everyone will have some problem performing a sex act. Fatigue, illness, stress, depression, and substance intoxication (alone or in combination) can make us either uninterested in sex or unable to perform sexually. When these everyday occurrences become persistent enough to disturb an individual or a relationship, the DSM–5 considers

AP President Bill Clinton signed Megan’s Law into effect in 1996. The law provides the pub- lic with access to certain information on the whereabouts of sex offenders so that residents may protect themselves and their children.

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them to be dysfunctions. Many of the dysfunctions are based on the work of Masters and John- son, whose description of the phases of the human sexual response cycle is addressed next.

Human Sexual Response Much of what we know today about the biological aspects of sexual behavior originated in the work of William H. Masters (1915–2001) and Virginia E. Johnson (1925–2013) in the 1960s (Masters & Johnson, 1967, 1970). They followed up Kinsey’s sociological research with direct observations of people engaging in sexual behavior under controlled laboratory conditions. Their work is not the last word, however. Later investigations have used increas- ingly sophisticated techniques, such as endoscopy and ultrasound imaging, to picture what really happens during sexual activity, especially during intercourse (Buisson, Foldes, Jannini, & Mimoun, 2010; Suh et al., 2004). These techniques have added much information to Mas- ters and Johnson’s original observations, although their main observations (described here) remain relatively unchallenged.

Masters and Johnson set out to describe how physical and psychological mechanisms work together to control sexual responsiveness. Before their observations, research attention was devoted primarily to understanding sexual genetics and anatomy. Their five phases of the sexual response cycle are described in the accompanying Highlight.

Highlight: Five Phases of the Sexual Response Cycle

1. Desire. A sexual cycle usually begins with desire, the motivation to engage in sexual activity. Desire can arise spontaneously or in response to a sexually arousing stimulus. In some cases, desire may not appear until sexual stimulation begins.

2. Excitement. The excitement phase begins with petting and foreplay, which causes sexual hormones to be secreted. Heart rate increases, and breathing becomes more rapid. The nipples become erect in women and in many men as well. Some women develop a sex flush, a body rash that deepens in color with their degree of sexual arousal. Blood flows to the genitals, causing the penis and the clitoris to swell and become red. The lining of the vaginal walls becomes lubricated.

3. Plateau. The genitals continue to fill with blood, and the muscles become tense. The penis becomes erect, and the testes enlarge and are pulled up into the scrotum. The clitoris retracts under its hood and the tissues of the vagina swell. Psychologically, feelings of sexual excitement increase. This stage can last for from a few minutes to several hours.

4. Orgasm. Females experience strong genital sensations and warmth spreading in the pelvic area, followed by rhythmic muscle contractions causing the vaginal walls, uterus, and rectal sphincter muscle to contract and expand. Males first feel the ejaculate coming, followed by muscle contractions in the penis that propel semen through the urethra and out the urinary opening. For both sexes, a psychological sensation of orgasm (pleasurable release) accompanies these muscle contractions.

5. Resolution. The body gradually returns to its prior unstimulated condition. For men, there is a refractory period in which they are unable to have another orgasm no matter how much they are stimulated. This period varies from less than an hour for some men to many hours for others, depending on their age, fitness, and a host of other factors. Women may have multiple orgasms with no apparent refractory period, but the ability to have multiple orgasms varies considerably from one woman to the next.

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The DSM–5 categorizes sexual dysfunctions according to the phase of the sexual response cycle that they affect: Disorders of sexual desire affect the initial phase, disorders that affect sexual arousal arise in the excitement and plateau phases, and disorders that affect orgasm mainly affect the orgasm phase. Most of the literature on sexual dysfunctions deals with het- erosexual couples. Similar sexual problems affect same-sex couples as well. However, for the sake of brevity, we will focus only on heterosexual couples in this chapter.

This chapter discusses each type of sexual dysfunction separately, but in practice they overlap and interact. For example, a person who cannot achieve an orgasm may lose the desire for sex and, hence, may wind up with both an orgasmic disorder and a disorder of desire. Such multiple dysfunctions are the rule rather than the exception. Also keep in mind that sexual dysfunctions are highly charged emotionally. Because sexual dysfunctions make it difficult or impossible for people to have or enjoy sexual relations, they may be extremely distressing to those who have them. Anger, fear, resentment, shame, guilt, and humiliation are frequently associated with sexual dysfunctions. If they persist, individuals may develop secondary disor- ders, particularly anxiety disorders and depression. These secondary disorders may be even more devastating to individuals and couples than are the sexual dysfunctions that trigger them.

Diagnosis Diagnosing a sexual dysfunction requires considerable clinical sensitivity. There is no objec- tive way to decide where normal behavior ends and a sexual dysfunction begins. For example, the failure to reach orgasm is not by itself a disorder. Many women, and some men, report satisfying sex lives without having orgasms. Failure to have an orgasm becomes a problem only if it causes distress or interpersonal difficulty. The same is true of all of the sexual dys- functions listed in the DSM–5; they are problems only when the people involved decide they are. Because sexual behavior is affected by physiology and mood, the DSM–5 requires that other potential disorders (such as depression), substance abuse, and general medical condi- tions be ruled out before deciding that a person is suffering from a sexual dysfunction. Before making a diagnosis, the clinician must also assess whether a person’s sexual performance is appropriate for his or her age (older people may require more stimulation than younger ones to become aroused or to reach orgasm). The clinician must also try to assess whether the person is getting adequate sexual stimulation. People with insensitive or inattentive partners may think they have a sexual dysfunction when they really have partners who don’t know how to fulfill them (or don’t care).

For each sexual dysfunction, the DSM–5 distinguishes between lifelong patterns that were present from the person’s first sexual activity and acquired ones that developed after a period of normal functioning. The latter are more likely to be the result of trauma or the second- ary effect of some other disorder. The DSM–5 also distinguishes generalized problems, which are not limited to certain types of stimulation, partners, or situations, from situational ones, in which the problems occur only with certain partners, certain types of stimulations, or in certain situations. The prognosis for situational problems is likely to be better than that for dysfunctions that occur in all sexual situations.

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Sexual Desire Disorders Desire is the complex set of feelings, cognitions, and fantasies that motivates people to engage in sex. Without desire, sex is little more than rubbing and friction. Women or men who, for whatever reason, lack desire for sex are said to have a sexual desire disorder. The DSM–5 describes two such disorders, one for each gender: male hypoactive sexual desire disorder and female sexual interest/arousal disorder.

If a man has male hypoactive sexual desire disorder, he has never had much interest in any type of real or fantasy sex, and this lack of interest may negatively affect his life. It also becomes more common with age (APA, 2013).

Although it is possible for male hypoactive sexual desire disorder to exist on its own, it rarely does. Disturbances in the other phases of the sexual response cycle—especially disturbances in sexual excitement or orgasm—frequently co-occur with male hypoactive sexual desire dis- order (Connor, 2011). In some cases, it is the inability to sustain sexual excitement or to reach orgasm that causes the person to lose interest in sex. Medical conditions, particularly those that cause pain during intercourse, various psychological disorders (depression and body dysmorphic disorder, to name two), and many drugs (including antidepressants) may also cause people to lose interest in sex.

Male hypoactive sexual desire disorder is one of the most common complaints of people who seek treatment for sexual problems (ISSM, 2011; Rosen & Leiblum, 1995); it affects approxi- mately 1.8% of men aged 16–44 (APA, 2013). Some people lack desire for any type of sexual activity. In other cases, a person may lack desire for some sex acts (intercourse, for example) but may desire others (such as masturbation). Men with male hypoactive sexual desire disor- der may not initiate sexual activity but may go along if the partner insists.

Like practically all behaviors, sexual desire forms a continuum. People who fall at the low extreme have little desire for sex. The majority, who fall in the middle of the continuum, have an intermediate level of desire. Those who fall at the high extreme have a strong desire for frequent sex. Interestingly, the DSM–5 does not contain a “hyperactive sexual desire disorder.” The authors of the DSM–5 may not believe that high levels of sexual desire can produce psy- chological problems.

Female sexual interest/arousal disorder represents the combining of sexual desire and arousal disorders into this single category. Unlike the male version, the criteria are far more specific here. The woman, for at least six months, has to show the following: absence or reduced interest in sexual activity; absent or reduced sexual or erotic thoughts or fantasies; none or reduced initiation of sexual activity and generally unresponsive to her partner’s ini- tiation attempts; absent or reduced sexual excitement or pleasure during sexual encounters at least 75% of the time; absent or reduced sexual interest or arousal in response to written, verbal, or visual erotic cues; and absent or reduced genital or non-genital sensations during sexual activity in at least 75% of sexual encounters (APA, 2013). The woman must demon- strate at least three of these criteria consistently over a six-month time period.

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Sexual Arousal Disorders Even when they desire to have sex, some people find it difficult to maintain the necessary level of arousal. That is, they have problems with the excitement phase of the sexual response cycle. The DSM–5 contains two sexual arousal disorders: female sexual interest/arousal dis- order and erectile disorder.

Women with female sexual interest/arousal disorder experience distress and personal dif- ficulty because they have absent, or significantly reduced, sexual interest or arousal (APA, 2013). The DSM–5 considers female sexual interest/arousal disorder to have psychological origins. Like the sexual desire disorders, arousal disorders can begin early in life or in adult- hood and can affect all sexual situations or just some. Not surprisingly, arousal disorders are usually accompanied by orgasm disorders—it is not normally possible to have an orgasm if one is not sufficiently aroused.

Erectile disorder is defined as an inabil- ity to attain or sustain an erection until the completion of a sex act. Erectile disorder replaced the older term impotence, which has false connotations (that the man is unable to have children or is an inadequate lover). Erectile disorder is the most com- mon reason men visit clinics for help with a sexual dysfunction. It also accounts for hundreds of thousands of doctor visits each year (Laumann, Paik, & Rosen, 1999). After age 40, more than half of all men have some degree of erectile difficulty from time to time. In general, older men need more stim- ulation and take longer to achieve an erec- tion than younger men. This is not a sign of

a psychological disorder but of normal aging (Gewirtz-Meydan & Ayalon, 2017). Substances (antihypertension drugs, alcohol, tranquilizers), medical disorders (diabetes, spinal injury), and psychological disorders (such as depression) may affect a man’s ability to attain or sus- tain an erection. However, the diagnosis of erectile disorder is normally reserved for men whose dysfunction appears to have a large psychological component. For example, males who have erections while masturbating or during sleep are physically capable of having erections; thus, their erectile dysfunction during sex is likely to have a psychological origin. They may feel guilty about sex or suffer from performance anxiety, for example. As in all sexual dys- functions, erectile disorder is diagnosed only when the dysfunction distresses the man or his partner.

Orgasmic Disorders Some people have the desire for sex, enjoy foreplay, and become excited but have consider- able difficulty achieving an orgasm. There may be physical reasons for this problem (medical conditions, substance intoxication) and psychological ones (such as performance anxiety). In some cases, both types of etiology are present simultaneously. An orgasmic disorder is

Creative Crop/Exactostock-1527 Sildenafil, popularly sold as Viagra, is com- monly used to treat male erectile disorder.

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diagnosed when psychological factors dominate. The DSM–5 describes two orgasmic disor- ders: female orgasmic disorder and premature (early) ejaculation.

Some women who have difficulty reaching orgasm lack interest in or are averse to sex in gen- eral. Such women are presumed to be uninterested in sex. However, there are women who are responsive to sexual stimuli as measured by self-report, vaginal lubrication, and genital swelling, but who nevertheless have great difficulty achieving an orgasm (Kaplan et al., 1996). Between 10% and 15% of women never experience an orgasm at all. Another 10% to 15% experience them only rarely. Because most of these women, and their partners, are not dis- tressed by their infrequent or nonexistent orgasms, they do not qualify for the diagnosis of female orgasmic disorder. By definition, this refers to a delay or absence of orgasm in some women following normal sexual excitation. It must also cause distress or interpersonal dif- ficulty (APA, 2013).

It is often difficult to determine whether a woman has an orgasmic disorder or whether she is just not getting the type or amount of stimulation she requires to achieve an orgasm. Women exhibit wide variability in the type and intensity of stimulation they require. Some women find intercourse sufficient stimulation to produce an orgasm, but many others do not. They are able to have an orgasm only when stimulated orally or manually. From a clinical viewpoint, a woman who fails to reach orgasm because she is not getting the stimulation she requires does not have an orgasmic disorder.

Premature (early) ejaculation refers to men who reach orgasm with minimal stimulation. For them, sex is over almost before it has begun. This reduces their satisfaction as well as the enjoyment of their partners. How quickly must a man reach orgasm for his ejaculation to be considered premature? There is no definitive answer. Some couples prolong intercourse for hours, whereas others are satisfied with a few minutes. In practice, ejaculation on insertion of the penis into the vagina or after a thrust or two is usually considered premature. The DSM–5 defines “premature” as ejaculation occurring within one minute following vaginal penetra- tion (APA, 2013). Even then, a man is considered to have a disorder only if he is personally distressed by his premature ejaculation or if it disturbs his partner. Premature ejaculation is common among young, relatively inexperienced men, especially those whose sex lives have been dominated by situations where speed may be important (to avoid discovery, for instance).

Genito-Pelvic Pain/Penetration Disorder Genito-pelvic pain/penetration disorder is a female-only disorder. It is marked by at least one of the following that must have been occurring for at least six months: difficulty with vaginal penetration during intercourse; vaginal or pelvic pain during intercourse or vaginal penetration attempts; fear or anxiety about vaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration; and marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration (APA, 2013, p. 437). Recurrent pain during intercourse is seen in approximately 15% of women in North America, but the prevalence of genito-pelvic pain/penetration disorder is unknown (APA, 2013). Pelvic pain during sex can vary from superficial to severe. In practically all cases, it causes distress to both the woman and to her partner. The disorder is diagnosed only when the pain is believed to have a strong psychological component. When the pain is solely the result of a substance, the person has substance/medication-induced sexual dysfunction.

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Genito-pelvic pain/penetration disorder can also be diagnosed when the perineal muscles surrounding the front part of the vagina contract involuntarily whenever vaginal penetration is attempted. The woman may have normal sexual desire and excitement and the ability to reach orgasm, but is unable to have intercourse. This can cause personal distress and dis- rupt relationships. The condition seems to be found most often in younger women who have negative attitudes toward sex and among victims of sexual abuse. This may be the result of a conditioned fear response to sex or may be the result of abuse or an insensitive lover.

Epidemiology and Course As we have seen, deciding whether a person has a sexual dysfunction takes considerable clini- cal skill. To make a diagnosis, the clinician must consider the person’s age, health, substance use, and cultural background and must determine whether the person is receiving the stimu- lation necessary to build excitement and reach orgasm. In addition, the clinician must assess the degree of distress produced by the dysfunction in the individual and, where appropriate, the distress produced in the individual’s partner.

Etiology Each phase of the sexual response cycle depends on an intricate balance of social, psychologi- cal, and physiological forces. Disruption in any of these forces may result in a sexual dysfunc- tion. Keep in mind, however, that the relationship between any single variable and a sexual dysfunction is never entirely predictable. If the sexual dysfunction is transitory and likely to disappear when the precipitating problem is resolved, the proper diagnosis is adjustment disorder. Adjustment disorders straddle the border between normality and pathology. They represent extreme but temporary reactions to everyday crises.

Once men begin having erectile problems, even occasionally, a vicious cycle may begin. The man begins to worry about his performance. His anxiety keeps him from becoming fully immersed in the sexual act. Instead, he takes on what Masters and Johnson call a spectator role—he watches his own reactions (“Am I developing an erection, or will I fail and be embar- rassed?”). As his anxiety becomes worse, the chances of erectile failure increase. This makes the man even more anxious, and the vicious cycle continues. See Figure 12.1 for more etio- logical factors.

Sexual Dysfunction

Lack of knowledge about sex

Depression

Adjustment reactions

Age-related changes

Substance use

Inadequate stimulation

Fear of intimacy

History of abuse

Relationship conflicts

Performance anxiety

Negative attitudes about sex

Low hormone levels

Figure 12.1: Etiological factors contributing to sexual dysfunction

Source: From S. Schwartz, Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, 2000, Figure 13.4, p. 583.

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Treatment Dysfunctions may be treated with physiological or psychological interventions. People whose sexual dysfunctions are caused by diseases such as diabetes may benefit from better treat- ment of their disease. People whose dysfunctions are the result of medications may benefit from having their medications reviewed and dosages adjusted. Getting people to stop using recreational drugs may also be helpful. In some cases, drug treatments may assist some peo- ple with sexual dysfunctions.

Drug Treatments Testosterone may help some men achieve and maintain erections (Block, Meiboom, Zaig, Sch- reiber, & Abramov, 2013). Hormone replacement therapy may help postmenopausal women maintain desire, reduce the pain of penetration or of vaginal intercourse, and provide an ade- quate level of vaginal lubrication. Although antidepressants may contribute to sexual dysfunc- tion, they may also help men with premature ejaculation to last longer. Women with tensing or tightening of the pelvic floor muscles during attempted vaginal penetration may be helped by a program in which metal rods (dilators) of gradually larger diameter are inserted into the vagina until the woman can relax the vaginal muscles sufficiently to accommodate a penis.

To assist men with erectile disorders, a series of operations was developed in which pumps were implanted into the penis and inflated when the man wished to have intercourse (Hunter, Goodie, Oordt, & Dobmeyer, 2017). These were soon supplanted by injectable drugs that pro- duced erections (Hatzimouratidis et al., 2016). Neither of these methods was particularly practical or pleasant, so they were rarely used. With the release of sildenafil (Viagra), as well as newer medications like tadalafil (Cialis) and vardenafil (Levitra), they have been rendered essentially obsolete. Viagra, which is successful at producing erections in most men with erectile disorder, has replaced practically all other drugs and surgical procedures. It is taken about one hour before the man plans to have sex, and its effects last for about four hours. Note that Viagra does not produce an erection by itself; it is still necessary for the man to be sexually stimulated. Rather, the drug increases blood flow to the penis, thereby allowing the stimulated man to produce an erection. Viagra seems to be effective for erectile disorders caused by medical conditions as well as for disorders whose origins are mainly psychological (Hatzimouratidis et al., 2016).

The drug has become so popular that it is even being used by men who do not meet the diagnostic criteria for erectile disorder but who believe it will enhance their performance (Gewirtz-Meydan & Ayalon, 2017). Despite its popularity, Viagra is not for everyone. Men with heart disease or circulatory disease who have not had sex for some time may find the strain of Viagra-induced sex too much for their weak hearts. Initially it was believed, and some research substantiated this, that anyone who took medicine that contains nitrates (such as nitroglycerin used for circulatory disease) might find that Viagra made their blood pres- sure drop suddenly to a life-threatening level (Kloner & Jarow, 1999). More recent research has demonstrated that, in fact, there is no convincing evidence of any major safety issue when a male uses Viagra (Hatzimouratidis et al., 2016). In addition, Hatzimouratidis et al. (2016) found no cause and effect relationship between Viagra and cardiovascular events. Finally, the researchers did not find any new safety risks relating to cardiovascular events or to drug interactions. This included synergistic effects (Hatzimouratidis et al., 2016). Cialis and Levi- tra produce results similar to Viagra (Hatzimouratidis et al., 2016). Although Viagra is clearly

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useful and popular, it is important to remember that the drug is not a cure (Segraves & Seg- raves, 1998). Take the drug away, and erectile dysfunction returns. Psychological treatments, by contrast, are aimed at ameliorating sexual dysfunctions and preventing their return.

Psychological Treatments Until the middle of the 20th century, the psychological treatment approach to sexual disor- ders was the same as for other psychological disorders. This was not only expensive and time consuming, but it also was rarely effective. In the 1950s, behavioral psychologists attempted to devise more efficient and effective treatments for sexual dysfunctions. Masters and John- son’s approach to treating sexual dysfunctions has been augmented and expanded over the years to form what is known today as sex therapy (Frühauf, Gerger, Schmidt, Munder, & Barth, 2014). Modern sex therapy consists of a combination of treatment techniques that include sex education, communication skills training, cognitive-behavioral therapy, couples’ therapy, and, when necessary, insight-oriented therapy (Frühauf et al., 2014). In some cases, sex therapy also includes treatment for associated psychological disorders, such as substance abuse, anxiety, or depression.

Although people with psychological disorders need treatment that is tailored to their individ- ual needs, there are some common factors that apply to most people with sexual dysfunction. First, treatment is almost always focused on couples, even though it is usually just one part- ner who has the identified problem. Second, educating couples about sex is crucial. Ignorance and misinformation about sex are important factors in almost every sexual dysfunction. (The accompanying Highlight debunks some common myths about sex.)

Highlight: Sex Myths

Although sexual dysfunctions and disorders have a multitude of interacting causes, ignorance about sex is almost always a contributor. Many of us are influenced by descriptions of sex in the media, which have contributed to unrealistic expectations and leave many people feeling inadequate. Some of the most common myths about sex are summarized here:

• Sex equals erection, intercourse, and orgasm. This common myth is one of the main causes of sexual performance anxiety. When people convince themselves that sexual fulfillment depends on reaching a goal (orgasm), deviations from reaching the goal, even temporary ones, are likely to lead to anxiety. In reality, erections, intercourse, and orgasms are unnecessary for pleasurable sex. Many couples report considerable satisfaction from kisses and caresses. Indeed, couples who learn to pleasure one another in circumstances where neither erections nor orgasms are required report more fulfilling sex lives than do those whose only goal is orgasm.

• When it comes to sex, men must take the lead. This Victorian-era view can interfere with the sexual enjoyment of both men and women. It can also keep a man from ever learning what his partner desires. A better approach is for partners to communicate their needs and desires and to share responsibility for initiating sexual activity.

• Men are always ready for sex. This is another anxiety-producing myth. Men who believe it become anxious whenever they fail to become excited immediately. In reality, men as well as women need to feel comfortable with their partner and with the situation in order to engage in pleasurable sex.

(continued)

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Section 12.2 Sexual Dysfunctions

Without such information, people often hold themselves to impossible standards. Similarly, attitudes and maladaptive cognitions (“sex is dirty”) need to be countered before progress can be made. A third common factor in practically all treatment programs is the need to over- come embarrassment and guilt about one’s sexual needs and preferences. To accomplish this, individuals and couples in treatment may be asked to explore their bodies and to experiment with masturbation in order to identify what gives them pleasure. Once they discover their particular preferences, they must then learn to communicate these to their partners. For a fulfilling relationship, partners need to know what gives their lovers pleasure, and what does not.

Masters and Johnson developed sensate focus as a way of helping couples learn about the sex practices that give them pleasure. Sensate focus requires that one partner actively stimulate the other, who focuses on the pleasurable feelings being induced. The couples then switch roles, so that each takes a turn giving and receiving stimulation. As they learn more about what gives them pleasure and communicate this to one another, they gain confidence. Couples may also undergo cognitive restructuring to change mistaken attitudes and beliefs about sex. Gradually, the couple proceeds to genital caresses and stimulation. They do not move on to intercourse until they can do so untroubled by performance anxiety. Masters and Johnson reported success rates of around 80% for their treatment. Some studies have reported less spectacular results, but sensate focus is still the treatment of choice for most couples (Früh- auf et al., 2014).

Specific techniques have also been developed to deal with particular sexual dysfunctions. For example, the start-stop technique for treating erectile disorder begins with the partner’s caressing the man until he gets an erection and then stopping. When the erection disappears, the partner repeats the caresses until the man is once again erect and then stops. When this start-stop cycle is repeated many times, the man gains confidence in his ability to achieve erections. He learns that his erections occur naturally in response to stimulation (provided that he does not focus on his performance).

• Women are not aroused by erotic films and books. This is untrue. Many women find such materials stimulating—just have a look at the stories and pictures in magazines aimed at women.

• Normal women achieve orgasm every time they have sex. Again, this may happen in the movies and in erotic literature, but it is not the case in real life. Individual differences allow some women to reach orgasm more easily than others. Even those women who reach orgasm easily do not have orgasms every time they have sex. Multiple orgasms are rarer still.

• Menopause is the end of a woman’s sex life. Although women who do not receive hormone replacement therapy may experience vaginal dryness, which can cause pain during intercourse, this is easily rectified by the application of vaginal lubrication. Many postmenopausal women report that not having to worry about pregnancy makes sex more pleasurable than when they were younger.

• Sex should be spontaneous rather than planned. This may work in the movies, but in many people’s busy lives, sex does not take place without planning.

Highlight: Sex Myths (continued)

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Section 12.3 Gender Dysphoria

The treatment of premature (early) ejaculation may include a technique known as pause and squeeze. The male is stimulated until he signals that he feels orgasm coming. At that point, the partner stops stimulating the male and squeezes his penis—preventing orgasm. As this is repeated, ejaculation is gradually delayed. The couple then switches to vaginal stimulation in which brief periods of entry are followed by stopping until the male is able to engage in inter- course for a reasonable period of time without ejaculating. These specific techniques work best when they are embedded in a multimodal treatment program that includes not just sex therapy but also education and cognitive restructuring (Hunter et al., 2017).

12.3 Gender Dysphoria Our sense of ourselves as male or female is known as our gender identity. Most of the time, gender identity is consistent with physical anatomy. Con- sider, for example, the case of Billy Tipton, a trans- vestite jazz musician who married five wives and was found to be a biological woman only on death (Middlebrook, 1998). Born Dorothy in 1914, Tipton was raised at a time when jazz was a man’s world. To have a career, a female musician had no choice but to pretend to be male. Tipton’s impersonation must have been excellent because it fooled not only his fellow musicians but also his various wives. Exactly how Tipton managed sexually is something of a mystery, but his amazing life demonstrates that gender identity is a social and cultural construct that is only loosely related to the biological facts (McConaghy, 1997).

Description and Diagnosis Children may sometimes become confused about their gender identity. Some become con- vinced that their physical anatomy and their gender are in conflict. They may look like males, but emotionally they feel like females (or vice versa). According to the DSM–5, such people may have gender dysphoria. People with gender dysphoria report that, even as children, they felt trapped in the wrong body (Berlin, 2016). Males say they were too “pretty” to be boys, whereas girls report feeling masculine (McDermid, Zucker, Bradley, & Maing, 1998). Gender dysphoria—especially for females—is rare. For adult natal (at birth) males, the range is between 0.005% and 0.014%; for natal females, the range is from 0.002 to 0.003% (APA, 2013). In adolescence, the ratio of males to females is about equal, but in adults the ratio of males to females ranges from 1:1 to 6.1:1 (APA, 2013).

Boys with gender dysphoria may dress in female clothing and adopt behaviors associated with female sex roles. Some may even wish for their penises to disappear. Girls may act like boys. Such children may find themselves ostracized by their peers. Their loneliness may lead to depression and other psychological disorders. Children then reach adolescence still confused

AP Although jazz musician Billy Tipton, center, was biologically a woman, he spent most of his life passing as a man.

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Section 12.3 Gender Dysphoria

about their gender identity. When sexual maturity occurs during adolescence, their biological sex becomes glaringly obvious. They can no longer pretend to be the opposite gender. To fit in, some learn to repress their feelings and play the sex role appropriate to their anatomy. A small number find this impossible; they endure adolescence and enter adulthood still wish- ing they were the opposite sex. Some decide to alter their sex through surgery.

Note that boys with gender dysphoria are not transvestic fetishists (they do not cross-dress to become sexually aroused), nor are they always gay males (Berlin, 2016). Gay males rarely wish to change their biological sex.

Etiology The etiology of gender dysphoria is not clear (Berlin, 2016; Zucker et al., 2015). It appears that brains may be “masculine” or “feminine” irrespective of whether the person has mascu- line or feminine genitalia.

The notion that brains have a gender identity separate from the genitalia is also consistent with the observations made of people born with a condition once known as pseudohermaph- roditism (note that persons born with aspects of both female and male genitalia are rare, and that the condition may be corrected by surgery). An individual with a disorder of sex develop- ment (this has also been called intersex, but this term is less common) is a genetic male whose genitalia do not fully develop before birth. These individuals are born looking like females and are usually raised as girls. They wear dresses and are encouraged to play female roles. This suggests that gender identity is determined more by the “sex” of a person’s brain than the appearance of a person’s genitalia.

It has not been possible to demonstrate that all people with gender dysphoria have been exposed to opposite-sex hormones during fetal development. Some may have developed gen- der dysphoria for other reasons, such as the sexual trauma caused by abuse. In some cases, children who have the appearance of the opposite sex (pretty boys, tomboyish girls) may have been strongly reinforced for taking the opposite sex role (Fridell, Zucker, Bradley, & Maing, 1996; McDermid et al., 1998). Eventually, they may have simply come to accept that they are the opposite sex. At the present time, similar to many of the other disorders discussed throughout the text, the cause of gender dysphoria is most likely to be found in a combination of biological and psychological factors (Berlin, 2016).

Treatment There are two ways to treat gender dysphoria: change the person’s sex role identity to match his or her anatomy, or change the anatomy to match the identity. The first option involves an immense psychological effort, which is not often successful. Hence, the option of changing anatomy has been taken up by thousands of people. Treatment usually begins by having the person live as the other sex for a trial period. During this period, the person is carefully moni- tored for other psychological disorders. Changing the sex of someone with a psychological disorder other than gender dysphoria is neither ethical nor sensible. People who are helped to overcome another psychological disorder may decide that they are perfectly happy with their existing sexual anatomy.

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Chapter Summary

During the trial period, sex hormones are administered to produce many of the physical char- acteristics of the other sex. Specifically, men are given estrogen, which causes them to develop breasts and makes their body and facial hair disappear. Testosterone is given to females to deepen their voices, increase their muscle mass, and cause body and facial hair to develop. Some people stop at this point, content to live as if they were the other sex. Some go all the way and have sex-change surgery, during which external genitalia are removed. For men a vagina is created by inverting the penis into the abdominal cavity. Females are given artifi- cial penises, which may be augmented with pumps or other erection-imitating mechanical devices, since they do not produce the normal male sexual response. Most people are satis- fied with the results of their sex-change operations and go on to lead rewarding lives (Berlin, 2016). A small number, particularly those with other psychological disorders, continue to have problems.

Chapter Summary

Defining Abnormal Sexual Behavior • Acceptable sexual behavior is defined by cultural norms. Activities considered nor-

mal in one culture may be prohibited in another. • What is considered normal in the present time might not have been considered nor-

mal in the past. • Normal means that the behavior as a whole is accepted by society as being proper

and acceptable.

Paraphilic Disorders (Paraphilias) • The paraphilic disorders are characterized by unusual, disturbing, or harmful sexual

fantasies and urges about sex with nonhuman objects, sex that involves suffering on the part of oneself or one’s partner, or sex with children.

• Some paraphilic disorders are exaggerations of everyday behavior; others involve serious crimes. Note, however, that not all apparently sexual crimes are paraphilias.

• Despite their diverse range, paraphilic disorders share a common characteristic—in every case, sexual behavior has been disconnected from a loving, consensual rela- tionship with another adult.

• Because paraphilic disorders occur mainly in men, researchers have assumed that they must have some hereditary sex-linked cause, although no such etiology has been uncovered.

• There is some evidence that people with paraphilic disorders have childhood and adolescent experiences that may have distorted their sexual interests.

Sexual Dysfunctions • Sexual dysfunctions are difficulties in sexual performance. Dysfunctions may affect

any of the stages of human sexual response (desire, excitement, plateau, orgasm, resolution).

• Although they are described as separate disorders, sexual dysfunctions often occur together.

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Chapter Summary

• Diagnosing sexual dysfunction requires clinical sensitivity; the clinician must try to assess whether the person is getting adequate sexual stimulation.

• The DSM–5 includes two disorders of sexual desire, one for men and one for women: male hypoactive sexual desire disorder and female sexual interest/arousal disorder.

• Female orgasmic disorder is diagnosed when a woman has difficulty achieving orgasm.

• Premature (early) ejaculation applies to men who reach orgasm too quickly. • Genito-pelvic pain/penetration disorder involves pain during sexual intercourse

and/or tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.

• For genito-pelvic pain/penetration disorder, the clinician must assess whether there are physiological causes or psychological causes leading to physiological symptoms.

• Sexual dysfunctions are common and are influenced by medical conditions, sub- stances, and psychological factors (especially performance anxiety).

• Many sexual dysfunctions require multimodal sex therapy—a combination of treatment techniques that includes sex education, communication skills training, cognitive-behavioral therapy, marital therapy, and insight-oriented therapy when necessary.

Gender Dysphoria • Our sense of ourselves as male or female is known as our gender identity. • People with gender dysphoria are not transvestic fetishists (they do not cross-dress

to become sexually aroused), nor are they gay. • Gender dysphoria may have hormonal origins, or it may be the result of early learn-

ing experiences. • Treatment involves changing the person’s sex role identity to match his or her

anatomy or changing the anatomy to match the identity (usually through surgery).

Critical Thinking Questions

1. Sexual sadism and sexual masochism disorder might be lifestyle choices or alterna- tive forms of achieving pleasure. For others these are seen as deviances and fetishes. Discuss your position on these two diagnosable conditions, being sure to provide detailed support for your position.

2. Many of the paraphilic disorders discussed do not respond well to treatment and are incurable. Knowing this, how would you treat someone with a paraphilic disorder? Should we attempt to treat such an individual, or are we “wasting” everyone’s time by making this attempt?

3. The FBI revised its (and thus the United States’) definition of rape in 2012, by removing gender specification, among other updates. How important is this change? Can a male be raped?

4. Let’s presume that you were asked to update Masters and Johnson’s research based on what we know today. Discuss which topics you would research, and describe the experiments you would devise to research these topics.

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Chapter Summary

Key Terms adjustment disorder An extreme but tem- porary reaction to an everyday crisis; these responses usually fade over time without intervention.

BDSM An acronym that stands for bond- age & discipline/dominance & submission/ sado-masochism.

desire The complex set of feelings, cogni- tions, and fantasies that motivates people to engage in sex.

erectile disorder An inability to attain or sustain an erection until the completion of a sex act.

exhibitionistic disorder A condition characterized by exposing one’s genitals to a stranger, sometimes accompanied by masturbation.

female orgasmic disorder In women, trou- ble reaching orgasm despite being sexually excited.

female sexual interest/arousal disor- der A problem that occurs when a woman experiences distress and personal diffi- culty because she lacks, or has significantly reduced, sexual interest or arousal.

fetishistic disorder Sexual gratification obtained using nonliving objects, such as shoes, bras, underpants, or leather cloth- ing, in fantasy or directly to achieve sexual gratification.

frotteuristic disorder Involves a male touching or rubbing up against females, usu- ally in crowded places.

gender dysphoria A discomfort with one’s assigned sex role.

genito-pelvic pain/penetration disor- der When a woman has difficulties with vaginal penetration during intercourse; pain during penetration attempts or during vaginal intercourse; or tensing or tightening of the pelvic floor muscles during attempted vaginal penetration, making penetration dif- ficult or impossible.

hypoxyphilia The practice of achieving sexual gratification by depriving oneself of oxygen by hanging from a noose or put- ting a plastic bag over one’s head to achieve sexual arousal or orgasm; also called asphyxiophilia.

male hypoactive sexual desire disorder A persistent lack of interest in any type of real or fantasy sex and a significant reduction or lack of physical arousal; this lack of interest negatively affects the man’s life.

paraphilic disorder (paraphilia) A condition characterized by intense sexual fantasies about, and urges to have (a) sex with nonhuman objects (bras or panties, for example), (b) sex that involves suffering on the part of oneself or one’s partner, or (c) sex with children.

5. We have discussed using medications to treat many disorders. In this chapter, we discuss Viagra and other medications. Discuss the pros and cons of using Viagra or one of the other medications listed to treat erectile disorder. In addition, what would your views be if a similar medication were available for females?

6. One method for treating gender dysphoria is surgery to change the individual’s geni- talia. Since this method is irreversible, discuss your views on this rather drastic form of treatment.

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Chapter Summary

pedophilic disorder Fantasizing about or engaging in sex with prepubescent children.

premature (early) ejaculation Orgasm after a brief period of stimulation, before the male (or the partner) wishes it.

rape The penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim. The FBI’s updated definition removed the phrase “carnal knowledge of a female forcibly and against her will” from the previous definition.

sensate focus A form of sex therapy (though some view it as a technique); it requires one partner to actively stimulate the other, who focuses on the pleasurable feelings being induced. The couples then switch roles, so that each takes a turn giving and receiving stimulation.

sex therapy Treatment techniques that include sex education, communication skills training, cognitive-behavioral therapy, cou- ples’ therapy, and, when necessary, insight- oriented therapy.

sexual dysfunction Difficulty in performing sexual act(s).

sexual masochism disorder Sexual gratifi- cation that involves real or imagined humili- ation and suffering inflicted upon the self to achieve sexual excitation or orgasm.

sexual sadism disorder Fantasizing about inflicting or actually inflicting suf- fering or humiliation on another for sexual satisfaction.

transvestic fetishism Cross-dressing for sexual pleasure by heterosexual males.

voyeuristic disorder Sexual fulfillment and excitement gained by watching unsuspecting people disrobe or engage in sex.

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