Ch. 12 Sexual Dysfunction, Gender Dysphoria, Paraphilias

sexual dysfunctions

impairment either in the desire for sexual gratification or in the ability to achieve it

What are the first three phases of sexual response?

1. desire: fantasies about sex

2. arousal: sexual pleasure and physiological changes

3. orgasm: release of sexual tension

What percentage of women and men experience sexual dysfunction?

4% of women and ~32% of men

male hypoactive sexual desire disorder

when a man shows little or no sexual drive or interest for at least 6 months

may be caused by alcohol use, stress, being unmarried, and poor health

erectile disorder

inability to obtain or maintain an erection sufficient for sexual intercourse

lifelong erectile disorder

has never maintained an erection

acquired/situational erectile disorder

at least one successful erection but typically cannot

early ejaculation

persistent and recurrent onset of orgasm and ejaculation with minimal sexual stimulation

delayed ejaculation

inability to ejaculate after a normal sexual excitement phase

genito-pelvic pain/penetration disorder

recurring difficulties of vaginal penetration or pelvic pain during intercourse for 6+ months

female orgasmic disorder

persistent or recurrent delay in, or absence of, orgasm after excitement phase. highest in 21-24 yr olds

gender dysphoria

persistent discomfort about one’s biological sex or the sense that the gender role of that sex is inappropriate

DSM-5 criteria gender dysphoria (adults)

marked incongruence between assigned gender at birth vs. experienced gender identity

at least 2 of the following:

• incongruence between experienced gender & sex characteristics

• strong desire to eliminate sex characteristics

• strong desire for the sex characteristics of the other gender

• strong desire to be a member of the other gender

• strong desire to be treated as the other gender

• conviction that feelings and reactions are those more characterized by the other gender

• the above are associated with clinically significant distress or impairment

DSM-5 criteria gender dysphoria (children)

at least 6 of the following:

• a strong desire to be the other gender or an insistence that one is the other gender

• in boys, a strong preference for cross-dressing or stimulating female attire; or in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing

• a strong preference for cross-gender roles in the make-believe play or fantasy play

• a strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender

• a strong preference for playmates of the other gender'

• in boys, a strong rejection of typically masculine toys, games, & activities and a strong avoidance of rough-and-tumble play; or in girls, a strong rejection of typically feminine toys, games, and activities

• a strong dislike of one’s sexual anatomy

• a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

What is the typical trajectory in kids with gender dysphoria?

Most children with gender dysphoria do not become adults with gender dysphoria (but most adolescents with it do!)

branch point around age 10-13 where gender dysphoria either “persists or desists”

Simply being transgender…

is not sufficient for a diagnosis of gender dysphoria

Treatment for gender dysphoria

1. psychotherapy → develops coping skills for discrimination & maltreatment

2. social transition → changing name & pronouns, outfits and social presentation

3. biological + surgical treatments → hormone replacement therapy, sex change surgery

Gender clinics

grappling with sharp and poorly understood rise in gender dysphoria/transgender identity - prevalence is increasing rapidly

What is the change in demographic for transitioning?

early 2000s: far more common for males to want to transition

now: far more common for females to want to transition

Do people “regret” transitioning?

Majority do NOT report regret

Paraphilia

abnormal sexual interest (ex: foot fetish) but you feel good about it

Paraphilic disorder

abnormal sexual interest (foot fetish) and you feel intense distress, guilt, shame about it

What are the 8 paraphilic disorders in the DSM-5?

voyeuristic, exhibitionistic, frotteuristic, sexual sadism, sexual mascochism, fetishistic, transvestic, pedophilic

Voyeuristic

watching others disrobe or engage in sexual activities

Exhibitionistic

intentional exposure of one’s genitals to others without their consent

Frotteuristic

rubbing pelvic or erect penis against a nonconsenting person

Sexual sadism

inflicting physical or psychic pain or humiliation on a sexual partner

Sexual masochism

stimulation and gratification from experiencing pain or degradation

Fetishistic

interest centers on an inanimate object or nonsexual part of the body

Transvestic

sexual arousal and satisfaction by dressing as a member of the opposite sex

Pedophilic

preferred or exclusive sexual partner is a prepubertal child (~13 or under)

What causes paraphilic disorders?

1. classical conditioning → pairing sexually deviant stimulus with sexual satisfaction

2. past sexual abuse

3. difficulties social skills/courtship - high rates of sadistic and masochistic paraphilias in autism - a more structured sexual “script” (Hammack lab)

Who has paraphilic disorders?

1. m:f ratio is 95:1

2. age of onset: ~8-12

sexual abuse

physical or psychological coercion or when one cannot consent

child sexual assault (CSA)

victims are 2x as likely to develop a later disorder + higher risks of suicidal thoughts and behaviors

Underlying motivations for CSA

varies- not CSA’s are committed due to pedophilia

• ~1/3 of childhood sexual abusers have pedophilia

why else?

• antisocial personality

• poor impulse control

• substance abuse

4 basic treatment goals for sex offenders

1. reduce arousal to targets

2. increase appropriate sexual interactions with adult partners

3. reduce behaviors that increase opportunity / chance of reoffending (ex: reduce alcohol use)

4. reduce general sex drive

Types of treatment for sex offenders

• Aversion therapy

• cognitive therapy

  • challenge the idea that it’s the child’s responsibility to stop sexual contact

• social skills training

  • how to talk to/court/sexually interact with same-age adults