Psych Disorders CH 10- Sexual Dysfunctions, Paraphilic Disorders, and Gender Dysphoria

There is more variation…

within a group than between groups

Sex

• Biological: XY or XX

• Male/Female/Intersex

• Chromosomes

• Sex organs

• Hormones

Gender

• Socially constructed and enacted roles and behaviors

• Man/Woman/Other

• Masculine/Feminine

• Gender Non-Conforming 

Sexual Orientation

Gender/Genders an Individual is sexually/romantically attracted to 

Things that need to be considered when defining normal vs abnormal sexual behavior:

• Normative (ex: common, average) facts and stats

• Cultural considerations

• gender differences in sexual behaviors and attitudes 

Key Findings from the IU National Survey of Sexual Health and Behavior: About 7% of adult women and 8% of men identoify as gay, lesbian, or bisexual 

• The proportion of people in the US who have had same sex sexual interactions at some point of their lives is higher than this

• The proportion of women who self-identify as bisexual is much higher than the number who self-identify as lesbian, especially among adolescent women 

Key Findings from the IU National Survey of Sexual Health and Behavior: Gender plays a critical role in understanding attitudes toward bisexual individuals among heterosexual, gay/lesbian, and other-identified adults

• In general, women are more likely to report positive attitudes toward bisexual individuals than men

• Attitudes toward bisexual women are more positive than men

Key Findings from the IU National Survey of Sexual Health and Behavior: Among people in relationships 

• 89% reported in monogamous partnerships 

• 4% reported open relationships 

• 8% reported being supposedly monogamous 

People who identify as gay, lesbian, and bisexual were less likey to

report monogamy and more likely to report open relationships and non consensual non-monogamy 

Women who orgasmed more frequently reported recieving

more oral sex, having sex for longer durations, and being more satisfied with their relationships 

Potential reasons for the gender difference in orgams frequency

• Stigma against female pleasure puts greater emphasis on men’s orgasms than women’s (though seems less is more recent generations) 

• Mistaken belief that most women will orgasm from vaginal sex alone 

• Many women are more dissatisfied with their appearance than men, making them more self-conscious about their bodies during sex 

What are the two most common reasons couples seek therapy?

Finances and sexual dissatisfaction

There are at least slight gender differences in:

• acceptability of casual or premarital sex (men > women) 

• Number of sexual partners (men>women)

• Rates of masturbation (men > women) 

• “Sexual self-schema” : women tend to be more embarrassed, conservative, self conscious about sex 

No gender differences in:

• Attitudes toward same-sex sexual behaviors (accepting)

• Attitudes towards masturbation (accepting)

• Views toward sexual satisfaction (important for both men and women) 

What are some cultural differences?

• Acceptability of premaritial sex

• Acceptability of homosexuality

• Perceived importance of sex

• Reasons for sex (Ex: personal pleasure) 

The development of sexual orientation is due to

• interaction of bio-psycho-social influences

• Genes higher in women 34-39% than men 18-19% (stronger environmental influences) 

  • Envi factors can include in utero hormone exposure 

• Know little abt fluid vs stable across life 

Sexual dysfunctions

• involve desire, arousal, orgasm, or pain

• must be present for 6+ months to meet criteria for a diagnosis 

• must lead to impairment or distress to be considered a disorder 

Human sexual response cycle - Desire Phase

Sexual urges occur in response to sexual cues or fantasies

Human sexual response cycle - Arousal stage

A subjective sense of sexual pleasure and physiological signs of sexual arousal;

• Males: Penile tumescence (increased blood flow to penis)

• Females: Vascocongestion (blood pools in pelvic area) leading to vaginal lubrication and breast tumescence (erect nipples) 

Human sexual response cycle - Plateau phase

Brief period occurs before orgasm

Human sexual response cycle - Orgasm phase

• Males: feeling of ejaculation, followed by ejaculation

• Females: contractions of the walls of the lower third of the vagina 

Human sexual response cycle - Resolution phase

Decrease in arousal occurs after orgasm (particularly men)

Classification of Sexual Dysfunctions

• Lifelong vs acquired

• Generalized vs situational

• Psychological factors alone

• Psychological factors combined with medical condition 

Male hypoactive sexual desire disorder

Little or no interest in any type of sexual activity, including masturbation and fantasies

Female sexual interest/arousal disorder

Reduced sexual interest, activity, fewer sexual thoughts, reduced arousal to sexual cues, reduced pleasure or sensations during almost all sexual encounters 

Erectile disorder

• difficulty achieving or maintaining an erection

• sexual desire is intact

• most common problem for which men seek treatment

• prevalence increases with age

• Female sexual interest/arousal disorder

Premature ejaculation

• occuring within about a minute of penetration and before it is desired 

• Most prevalent sexual dysfunction in adult males

• Affects 21% of all adult males

• Most common in younger men with less sexual experience 

Delayed ejaculation

Treatment rarely sought

Female orgasmic disorder

• Marked delay, absence, or decreased intensity of orgasm after normal arousal phase with almost all sexual activities 

• Not explained by relationship distress or other significant stressors 

Genito-pelvic pain/penetration disorder

• Females: difficulty with vaginal penetration during intercourse, associated with one or more of the following: 

  • Pain during intercourse or penetration attempts

  • Fear/anxiety about pain during sexual activity

  • Tensing of pelvic floor muscles in anticipation of sexual activity 

Sexual dysfunctions are only problems for older people…

Does increase with age but can occur at any age

There is no need to get treatment for sexual disorders unless they are severe…

Treatment may be advised

Erectile dysfunction is the only sexual problem that can be reliability treated…

There are other very effective treatments for other sexual dysfunctions as well

Sexual dysfunction is all mental

Although thoughts and feelings, notably anxiety, can influence sexual functioning, physical health is also an important determinant, as may be the use of alcohol or other substances and medications and relationship issues may also play an important role 

Dysfunction occurs only when people no longer find their partner attractive

Although relationship issues may play a role in sexual dysfunctions, many other factors are also important 

Sexual dysfunction can’t be prevented

Can be prevented by education, maintaining good physical health, and through open and honest communication between partners 

Ways to assess sexual behaviors

• Detailed interviews

• Medical evaluation

  • Medication side effects

  • Physical conditions 

• Psychophysiological assessment 

  • Sexual arousal in response to erotic material 

  • Males —Penile strain gague (measure erection)

  • Females—Vaginal photoplethysmography (measures blood flow to the vagina)

Biological contributors

• physical disease

• chronic illness

• prescription medications (ex: antihypertensive medication)

• alcohol and drugs 

Psychological contributors

• People with sexual dysfunction are more likely to experience anxiety and negative thoughts about sexual encounters

• May actively avoid awareness of sexual cues

• May be a result of traumatic experiences 

Erotophobia

associate sexiality with negative feelings, anxiety, or threat

Social and cultural contributors

• unpleasant or traumatic sexual experiences

• poor interpersonal relationships

• lack of communication 

Masters and Johnson’s psychosocial intervention 

• Education about sexual response, foreplay, etc

• Sensate focus on nondemand pleasuring

  • Sexual activity with the goal of focusing on sensations without trying to achieve orgasm

  • Decreases performance anxiety 

Squeeze technique

premature ejaculation (psychosocial procedure)

Masturbatory training

Female orgasm disorder (psychosocial procedure)

Uses of dilators

Vaginismus (psychosocial procedure)

Exposure to erotic material

low sexual desire problems (psychosocial procedure)

Medical treatments for erectile dysfunction 

• Viagra or similar medications

• Injection of vasodilating drugs into the penis

• Testosterone

• Penile prosthesis or implants

• Vascular surgery

• Vacuum device therapy

Not many for female sexual dysfunction 

Paraphilic disorders

misplaced sexual attraction and arousal

• focused on inappropriate people or objects 

• often multiple paraphilic patterns of arousal

• high comorbidity with anxiety, mood, and substance use disorders 

Paraphilia is not a disorder unless

it’s associated with distress and impairment or harm or the threat of harm to others

Frotteuristic disorder

persistent pattern of seeking sexual gratification from rubbing up against unwilling others

Fetishistic disorder

sexual attraction to nonhuman objects or highly specific focus on nongenital body part(s)

Voyeuristic disorder

Observing an unsuspecting individual undressing, naked, or engaged in sexual activity for sexual gratification 

Exhibitionistic disorder

Exposure of genitals to unsuspecting strangers for sexual gratification

Transvestic disorder

Sexual arousal associated with the act of wearing clothing of the opposite sex

Sexual sadism disorder

inflicting pain or humiliation to attain sexual gratification

Sexual masochism disorder

Suffering pain or humulation to attain sexual gratification

Pedophilia

• sexual attraction to prepubescent children

• vast majority are males

Associated features of Pedophilia

• Incestuous males may be aroused by adult women

• Male pedophiles are usually not aroused by adult women

• Some try to rationalize behavior 

Covert sensitization

imagining aversive consequences to form negative associations with the unacceptable behavior 

Orgasmic reconditioning

Masturbation to appropriate stimuli

Medications that reduce ____ may be used in some populations like convicted sex offenders 

testosterone 

Gender identity

• Perception of being a man, woman, gender fluid, or nonbinary or some other experience

• Formed between 18 to 36 months of age 

• Not related to transvestic disorder or same sex attraction 

Gender Dysphoria": DSM-5 Criteria

• Must last more than 6 months, be associated with significant distress/impairment, and include more than 2 of the following: 

  • Marked incongruence between one’s experienced/expressed gender and primary and or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics) 

  • Strong desire to be rid of one’s primary and or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender( ot in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)

  • Strong desire for the primary and or secondary sex characteristics of the other gender

  • Strong desire to be of the other gender

  • Strong desire to be treated as the other gender 

  • Strong conviction that one has the typical feelings and reactions of the other gender 

Gender Dysphoria 

• Diagnosis is rare (more common in males) 

• Rates are similar across cultures 

• No clear biological cause identified but evidence of genetic influence 

Gender affirming surgery

• Must be psychologically/socially stable and live as desired gender first

• Most report satisfaction with surgical results 

Treatment of gender nonconformity in children

• controversial 

• options range from discouraging gender nonconformity to watchful waiting to supporting the transgender identity

• Medical treatment may include hormone blockers 

Disorders of sexual development

Characterized by ambiguous genitalia with documented hormonal or other physical differences 

What has been the standard treatment for individuals with disorders of sexual development? 

• Surgery and hormonal replacement therapy

• Wisdom of early surgical reconstruction of genitals is debatable