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Normal Sexual Behavior and Sexual Dysfunctions: What Are they?

Sexual Dysfunctions: Features and Epidemiology

Stigma Associated with Sexual Dysfunctions

Sexual Dysfunctions: Causes and Prevention

Sexual Dysfunctions: Assessment and Treatment

Normal Sexual Desires, Sexual Desires, Paraphilias and Paraphilic Disorders: What Are They?

Paraphilic Disorders: Causes and Prevention

Paraphilic Disorders : Assessment and Treatment

Normal Gender Development and Gender Dysphoria: What Are They?

Gender Dysphoria: Features and Epidemiology

Gender Dysphoria: Causes and Prevention

Gender Dysphoria: Assessment and Treatment

Sexual dysfunctions involve disturbance of the normal sexual response cycle and may be lifelong or acquired.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Normal Sexual Behavior and Sexual Dysfunctions: What Are They?

Sexual dysfunctions involve problems with the human sexual response cycle or pain during intercourse.

Sexual dysfunction refers to problems of desire, arousal, orgasm, or pain during intercourse, and are considered problematic if they cause distress and interfere with sexual or interpersonal functioning.

Male hypoactive sexual desire disorder involves lack of fantasies or desire to have sexual relations in men. If this is not a distressing situation to the person in question, the diagnosis would not apply.

Female sexual arousal disorder refers to lack of interest in or arousal in women during most sexual encounters.

Erectile disorder refers to difficulty obtaining or maintaining a full erection during sex.

DSM-5: Male Hypoactive Sexual Desire Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

DSM-5: Female Sexual Interest/Arousal Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

DSM-5: Erectile Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Female Orgasmic Disorder

Some sexual dysfunctions involve the orgasmic phase of sexual relations. Female orgasmic disorder refers to a delay or absence

of orgasm during sexual relations (as shown here in Table 11.4; APA, 2013).

DSM-5: Delayed Ejaculation

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

DSM-5: Premature (Early) Ejaculation

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

DSM-5: Genito-Pelvic Pain/Penetration Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Common

Increase with age

Co-morbid with one another

Co-morbid with anxiety and depression

May link to medical, substance, and cultural factors

Epidemiology of Sexual Dysfunctions

Sexual dysfunctions are common, increase with age, co-morbid with one another and with anxiety and depression, and may link to medical, substance, and cultural factors.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Negative mood

and expectancy

about gaining an erection

Focus on

consequences

of inability to

perform

Increased physical arousal

Intense focus on

consequences

of inability to

perform

Erectile

dysfunction and

avoidance of sex

Demands or expectations for sexual performance

Causes of Sexual Dysfunctions

An integrated causal approach to sexual dysfunctions likely involves a combination of biological events and expectations that negative events will occur during sex.

Biological risk factors include certain medical conditions and substance abuse. Psychological risk factors include anxiety or worry about pleasing oneself or one’s partner, including the spectator role. Other psychological factors include early negative sexual experiences and lack of knowledge about sex over time.

Cultural factors can influence whether or not an event or experience is viewed as sexual dysfunction or not.

Prevention of these disorders focuses primarily on relapse prevention.

Stigma Associated with Sexual Dysfunctions

Stigma associated with sexual dysfunctions can be quite powerful

For men, “impotence” or erectile dysfunction

For women, recurrent painful intercourse, infertility

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Focus on College Students: Sexual Dysfunctions

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Items from the Female Sexual Function Index

Over the past 4 weeks, how often did you feel sexual desire or interest?

5 = Almost always or always

4 = Most times (more than half the time)

3 = Sometimes (about half the time)

2 = A few times (less than half the time)

1 = Almost never or never

Assessment of Sexual Dysfunctions

Interviews for sexual dysfunctions cover sexual history, knowledge, beliefs, desires, and practices as well as relevant relationship issues.

Self-report questionnaires are useful for assessing sexual dysfunctions and focus on sexual satisfaction, arousal, anxiety, preferences, attitudes, and knowledge. Questionnaires may contain items like the one pictured here from the Female Sexual Function Index.

Self-monitoring is sometimes used as an assessment technique for sexual dysfunction.

Physiological assessment of sexual dysfunctions includes nocturnal penile testing and other methods.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Biological Treatment of Sexual Dysfunctions

Penile implants help the male organ become rigid for penetration during sex.

Medical treatments for sexual dysfunctions are more available in recent years and include drugs such as Viagra, implants, vaginal lubricants, and hormone therapy.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Psychological Treatments of Sexual Dysfunctions

Sensate focus is a

sex therapy technique to enhance sexual pleasure for

a couple and reduce sexual dysfunction.

Psychological interventions for sexual dysfunctions concentrate on sex therapy. For example, to address premature ejaculation a stop-start procedure may be employed.

For low sexual desire, couples may be encouraged to use sensate focus which involves easing the pressure on sexual performance and concentrating on rebuilding their sexual repertoire.

Masturbation training may be used for people with orgasmic disorders. Pain during intercourse may be addressed in a variety of ways, including use of Kegel exercises.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Long-Term Outcomes for People with Sexual Dysfunctions

Positive outcomes

Good relationship quality

High partner motivation

Lack of comorbid disorders

People with sexual dysfunctions generally respond well to treatment, especially if the couple is attracted to one another, communicates well, and complies with treatment.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Normal Sexual Desires, Paraphilias, and Paraphilic Disorders

Paraphilias are preferential, intense, and persistent sexual interests that are odd, but may not be a mental disorder.

Paraphilic disorders include problems rising from some such interests and behavior, include exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism and sadism, transvestism, and voyeurism.

DSM-5: Exhibitionistic Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.

The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if sexually aroused by exposing genitals to prepubertal children, mature individuals, or both. Specify if in a controlled environment or in full remission.

DSM-5 Exhibitionistic Disorder

Exhibitionistic Disorder

The particular focus of exhibitionism, or flashing or indecent exposure, is exposing one’s genitals to strangers who do not expect the exposure.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Fetishistic Disorder

The particular focus of fetishism is “nonliving objects” to begin or enhance sexual arousal.

DSM-5: Frotteuristic Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Frotteuristic Disorder

People with frotteurism prefer crowded places such as subways to seek victims.

The particular focus of frotteurism is physical contact with someone who has not given consent.

DSM-5: Pedophilic Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Pedophilic Disorder

The particular focus of pedophilia is sexual attraction to a child. For example, Phillip Garrido (pictured here) kidnapped fifth-grader Jaycee Lee Dugard, holding her captive and fathering two children by her.

DSM-5: Sexual Masochism and Sexual Sadism

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

DSM-5: Transvestic Disorder

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Transvestic Disorder

People with transvestism cross-dress for sexual excitement, sometimes in public.

The particular focus of transvestic disorder (or transvestism) is identification with or dressing as the opposite gender

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Voyeuristic Disorder

The particular focus of voyeurism is secretly watching others undress or engage in sexual activity without being seen.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Epidemiology of Paraphilic Disorders

Charting the exact prevalence of paraphilias is difficult because the behaviors are usually secret and rarely brought to a therapist’s attention.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Frontal lobe

Cingulate gyrus

Hypothalamus

Amygdala

Hippocampus

© photobank.ch/Shutterstock.com

Biological Risk Factors for Paraphilic Disorders

Paraphilias may relate to certain biological risk factors such as genetics, neuropsychological problems, and hormonal changes.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Poor social skills

Family variables

Learning experience

Cognitive distortions

Environmental Risk Factors for Paraphilic Disorders

Those with paraphilias may be introverted and have poor social and intimacy skills.

Family variables may contribute to paraphilias, including hostile family behaviors, poor attachment, and aggressive sexual activity within the home.

Paraphilias may come from learning experiences by associating a paraphilic object with masturbation and orgasm. Courtship problems may be learned as well.

People with paraphilias often have cognitive distortions to justify or rationalize their sexual behavior.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Biological predisposition toward hypersexuality

Problematic family environment: Inadequate attachment, maltreatment, poor development of social and sexual skills

Aberrant learning experiences regarding sexuality: Classical conditioning with odd sexual stimuli, deviant attachment and arousal to children, unusual fantasies reinforced by masturbation

Maladaptive cognitive and personality patterns: Rationalizations for odd sexual behavior, inability to suppress paraphilic thoughts, antisocial tendencies

Possible paraphilia

Causes of Paraphilic Disorders

The cause of paraphilias may involve hypersexuality, deviant sexual arousal, learning experiences, social skills deficits, and other important variables. Here is one possible developmental pathway showing how these are linked over time in a person’s experience.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Identity Disorder

Prevention of Paraphilic Disorders

Teaching appropriate social and sexual skills

Providing relapse prevention strategies

Preventing paraphilic disorders may involve teaching appropriate social and sexual skills as well as relapse prevention after one has been arrested or seeks treatment.

Offender has an unrelated victim (Yes = 1; No, related victims only = 0)

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Items from the Screening Scale for Pedophilic Interests

Offender has male victim (Yes = 2; No, female victims only = 0)

Offender has more than one victim (Yes = 1; No, single victim only = 0)

Offender has a victim aged 11 or younger (Yes = 1; No, child victims were 12 or 13 years old = 0)

Assessment of Paraphilic Disorders

Interviews with people with paraphilia often focus on paraphilic thoughts and behaviors as well as personality characteristics and comorbid problems.

Self-report questionnaires may be used to assess sexual history and unusual interests, hypersexuality, and sexually aggressive and pedophilic behavior.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Vaginal and rectal perineometers

A penile strain gauge

A vaginal photoplethysmograph

Biological Treatment of Paraphilic Disorders

Physiological assessment devices for sexual response.

Physiological assessment for paraphilias includes penile plethysmograph, vaginal blood volume, and measuring how long a person views erotic material.

Drug treatment for paraphilias aims to reduce testosterone and sex drive and to improve depression and compulsive behaviors.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Aversion treatment

Covert sensitization

Orgasmic reconditioning

Psychological Treatments of Paraphilic Disorders

Psychological treatments for paraphilias concentrate on aversion treatment to quell behavior, covert sensitization to punish the paraphilic urge, and orgasmic reconditioning associate pleasurable orgasm with more appropriate stimuli.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

78.6 – 95.6% respond positively to treatment

Long-Term Outcomes for People with Paraphilic Disorders

People with paraphilias do respond positively to treatment and tend not to be rearrested, though this may be due to reduced sex drive with age.

DSM-5: Gender Dysphoria (Part 1)

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

DSM-5: Gender Dysphoria (Part 2)

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender Development and Gender Dysphoria

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender

Development and

Gender Dysphoria

Gender Dysphoria: Features and Epidemiology

Young boys and girls typically play apart, but children with gender dysphoria may identify more with the opposite gender.

Gender dysphoria involves strong desire to be the opposite gender and strong dislike of one’s current sexual anatomy.

Gender dysphoria is quite rare, affecting .005 to .014% of men and .002-.003% of women.

No strong biological risk factors, including genetics, family history, and physical problems, have been supported. Some point to prenatal sex hormones as somehow related to the disorder. Exposure to opposite-gender hormones such as testosterone sometimes relates

Psychological risk factors include relationship problems with family and peers.

The diagnosis of gender dysphoria is not universally valid across cultures.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender

Development and

Gender Dysphoria

Biological & Psychological Treatment of Gender Dysphoria

Caitlyn Jenner has made headlines with her recent gender transition.

The primary biological intervention for gender dysphoria, particularly in adults, is sex reassignment surgery in which external genitalia and bodily features are modified to fit the characteristics of the opposite sex.

Psychological interventions for gender dysphoria focus on changing cross-gender behaviors.

Sexual Dysfunctions

Normal Sexual Desires and Sexual Disorders/Paraphilias

Normal Gender

Development and

Gender Dysphoria

Long-Term Outcomes for People with Gender Dysphoria

Children with gender dysphoria are thought to respond to behavior therapy better than adolescents

Youths who continue to show intense cross-gender behavior throughout their childhood may be more likely to develop gender dysphoria, especially for girls

Children with gender dysphoria are thought to respond to behavior therapy better than adolescents with the disorder because their sense of gender orientation as youngsters is more flexible. Adolescents and adults with gender dysphoria may be more successfully treated via sex reassignment surgery.

Chapter Reflections

What is the impact of the Internet on sexual fantasies and behaviors?

What separates “normal” sexual activity from “abnormal” sexual activity?

How would you respond to cross-gender behaviors in your child?