Ch9 Concepts: Sexual dysfunctions, paraphilic disorders, gender dysphoria

Sexual dysfunction: Sexual desire disorder

Male hypoactive sexual desire disorder: apparent lack of interest in sexual activity or fantasy

Sexual dysfunction: Sexual arousal disorder

1. Erectile disorder: recurring inability to achieve/maintain adequate erection

2. Female sexual interest/arousal disorder: recurring inability to achieve/maintain adequate lubrication

Sexual dysfunction: Orgasm disorders

1. Female orgasmic disorder: inability to achieve orgasm despite adequate arousal and desire

2. Premature ejaculation: ejaculation before it’s desired, with minimal stimulation

Sexual dysfunction: sexual pain disorders

Genito-pelvic pain/penetration disorder: marked pain, anxiety, and tension associated with intercourse for which there’s no medical cause

• Vaginismus in females: involuntary muscle spasms in the front of the vagina that prevents or interferes with sex

Major phases/stages of the normal sexual response cycle?

1. Desire phase: sexual urges in response to sexual cues/fantasies; libido, excitement

2. Arousal: subjective sense of sexual pleasure and physiological signs of sexual arousal; erection or vasocongestion

3. Plateau: brief period occurs before orgasm

4. Orgasm: ejaculation or contractions of walls of lower third of vagina

5. Resolution: decrease in arousal after orgasm

Sexual desire disorder: Male hypoactive sexual desire disorder

• little interest in sexual activity or fantasies; masturbation or sex is very rare

• 5% prevalence

Sexual arousal disorders

1. Female sexual interest/arousal disorder: little to no interest in sex/arousal

   1. Symptoms: decreased sexual interest, thoughts, activity

      1. Sexual cues have little to no arousal

      2. Sexual encounters: decreased pleasure or sensations

      3. Inability to achieve/maintain adequate lubrication

2. Erectile disorder: most common sexual problem to come in for treatment, usually caused by unrealistic expectations due to porn

   1. Sexual desire remains intact, but difficulty achieving/maintaining erection

   2. Primary ED: never had successful sex

   3. Secondary ED: at least 1 successful sex

   4. Over age 60: likelihood of ED increases by 60%

Primary Erectile Disorder ❌

Never had 1 successful sex experience

Secondary Erectile Disorder ✅

Had at least 1 successful sex experience

What is male orgasmic disorder?

Premature ejaculation, which is ejaculation that occurs before it’s desired (with minimal stimulation)

Characteristics of female orgasmic disorder?

1. Marked delay in orgasm, decreased intensity or absence (even with adequate desire, arousal, stimulation)

2. Not due to relationship distress or other stressors

3. 1 in 4 women have major difficulty achieving orgasm

Specific types of genito-pelvic pain/penetration disorders?

1. Dyspareunia: before, during, or after sex/penetration

2. Vaginismus: outer vaginal wall spasms or closes, clamping down

Describe what genito-pelvic pain/penetration disorders are and the symptoms.

• Sex with pain, anxiety, tension; not due to medical cause, anticipation involved

• 1 or more symptoms of:

  • difficulty with penetration

  • vaginal/pelvic pain in sex (dyspareunia, vaginismus)

• Fear or anxiety about pain w/ sexual activity/anticipation

• Tensing/tightening of pelvic floor muscles

Major issues that must be examined for a detailed sexual history and comprehensive interview?

• Sexual lifestyle and behaviors

• Associated Factors: Partner and relationship, individual vulnerabilities, cultural or religious issues, medical issues

• Medical exam to rule out medical causes/conditions

• Psychophysiological evaluation: view erotic materials and measure sexual arousal response

  • Male: penile strain gauge to measure erection, blood flow, how long you maintain erection

  • Female: vaginal photoplethysmography; tube device examining lubrication and blood flow

  • Do you have arousal that allows you to have more pleasurable sexual activity?

Biological explanations for sexual dysfunctions 🧬

• Neurological or nervous system problems: neuropathy (nerve damage) due to diabetes

• Physical and chronic illness: vascular disease (affects veins/arteries = blood flow)

• Prescription medications: anti-hypertensive medications that decrease blood pressure

• Alcohol or substance use: Depressant features slows blood flow, blood pressure

Psychological explanations for sexual dysfunctions 🧠

• Negative thought processes about sex: anxiety and negative thoughts about sex taught early on

• Avoiding awareness about sexual cues: Decreased ability to be in touch with sexual response (Ex: men with premature ejaculation distract themselves to avoid orgasm)

• Negative psychological profiles: Low self-esteem and confidence; worried about how they look and how they’re performing. Compromising their own sexual satisfaction; concerned about how they appear.

Social and cultural explanations for sexual dysfunctions?

• Erotophobia: irrational, excess guilt and fear about sexual feelings. (Ex: taught in childhood that sexual urges are taboo and alarming)

• Negative ‘learned’ attitudes about sexuality: dislikes talking about sex, negative views about explicit, sexual materials.

• Negative, traumatic sexual experiences: sexual abuse, rape

• Poor romantic relationships and communication: decreased sexual interest or pleasure

Combined psychological and physical influences are common explanations for sexual dysfunctions:

• Biological predispositions: past heart attack during sex

• Psychological factors: fears about another heart attack

• Can produce sexual disorder: increased fear of sexual intimacy, as it may cause a heart attack!

Medical treatments for sexual dysfunction? 🏥❌

Male erectile dysfunction: major research dedicated to it.

• Medications: Viagra; side effects: headaches, nausea may stop use

• Vasodilation drugs and testosterone: may require direct injection into penis to maintain an erection; unsatisfying.

• Penile prosthesis/implants and vacuum device therapy: mechanical methods to cause erection

• Vascular microsurgery: repairs nerve damage and increases blood flow

Female sexual dysfunction: Little research! Very few treatments or procedures

Not very effective…

Psychological treatments for sexual dysfunctions 🧠

• Premature ejaculation: squeeze technique to apply pressure at base of penis, by self or partner. Take thumb and index finger to place at base of penis.

• Female orgasmic disorder: masturbation training by self-exam with mirror to identify sensitive areas. What parts do they like and not like to be touched?

• Vaginismus, one of the Genito-pelvic disorders: use of dilators that provides gradual enlargement. Insertion without pain, now equate pleasure with the size of the dilator.

• Low sexual desire: exposure to erotic materials and masturbation

Sexual education alone is very effective for sexual dysfunction treatment because…

it provides basic facts, and having a casual convo is helpful 🙂

Masters & Johnson’s psychosocial treatment for sexual dysfunctions?

• Increased sexual education: Normalizing what your own sexual response is (doesn’t have to look like the ‘norm’), foreplay techniques

• Sensate focus and non-demand pleasuring: sensual touching and physical sensations without attempting orgasm. Reduce performance anxiety.

• Participation of both partners in sex

What are paraphilic disorders? 🦹

• misplaced sexual attraction and arousal that occurs for 6 months or more for inappropriate objects or nonconsenting people

• high comorbidity with anxiety, mood, and substance use disorders as they’re worried about people finding out/try to quell their attraction.

• Diagnosed only if it causes major clinical distress or impairment OR illegal/criminal acts with non-consenting persons

How are paraphilic disorders different from paraphilias?

Paraphilias are NOT diagnosed and aren’t illegal/criminal acts. They’re simply unusual sexual fantasies, urges, or behaviors where no major distress or impairment is caused.

Fetishism (paraphilic disorder) 👠

urges/arousal with inanimate/non-human objects (rubber, high heel shoes, female underwear)

Frotteurism (paraphilic) 🛗

inappropriate rubbing up against unwilling, non-consenting persons (crowded/confined spaces where they can’t escape in elevators, subways)

Voyeurism (paraphilic) 👀

watching unsuspecting person having sex/undressing. Gets arousal from the thrill of getting caught for “peeping”

Exhibitionism/flashers (paraphilic) 🍆

exposing genitals to unsuspecting strangers. Arousal from the element of thrill of getting caught!

Transvestism (paraphilic) 👗

• sexual arousal from cross-dressing or wearing clothing of the opposite sex (they don’t want to become the opposite sex, just enjoy wearing)

• Not due to gender dysphoria!

• Not usually compensatory masculine behaviors, as men are often married, and the wife knows.

• Only diagnosed if major distress or impairment

• Specifiers

  • Fetishism: arousal to clothes itself

  • Auto-gynephilia: aroused by others thinking they’re a woman

Sexual sadism (paraphilic)

arousal from inflicting pain/humiliation to another person

Masochism (paraphilic)

arousal from RECEIVING pain/humiliation

Sadomasochism (paraphilic; both sexual sadism AND masochism)

• likelihood of doing it to non-consenting individuals?

• Some rapists may be sadists, but most lack paraphilic arousal – they’re more aroused by violence/violent materials, NOT the sexual impact.

Pedophilia (paraphilic) 🧒

• sexual arousal to children, victims are usually pre-pubescent girls

• usually male perpetrators, rationalization is that they’re exhibiting love/affection, communicating it to children that don’t get it at home, and a way to “teach” about sexual experiences

• Incest: arousal to young family members and adult women. Pedophilia may be limited to incest only.

• Sexual urges = sexual behaviors

• Some never act on urges and instead exhibit moral compensatory behaviors: Anti-porn stance, devout church members

Causes of pedophilia?

• Difficulty with normal relationships: deficits in typical sexual experiences, problems with childhood relationships

• Early sexual experiences: childhood – sexual associations by chance are reinforced by sexual arousal and masturbation

• Higher sexual drive: trying to suppress unwanted fantasies leads to increased urges. Seeks inappropriate gratification by prostitutes and more.

Psychological assessment for pedophilia?

• Behavioral interventions: Decrease inappropriate associations

  1.      Covert sensitization: repeated images of negative outcomes creates negative association with inappropriate sexual urges/acts

  2.      Orgasmic reconditioning: repeated pairing of appropriate stimuli with masturbation creates more appropriate arousal patterns

• Family and marital therapy

• Coping and relapse prevention

Psychological treatment for paraphilic disorders (behavioral interventions to decrease inappropriate associations)

• Covert sensitization: repeated images with negative outcomes creates negative association with inappropriate sexual urges/acts

• Orgasmic reconditioning: repeated pairing of appropriate stimuli with masturbation creates more appropriate arousal patterns

• Family and marital therapy: address negative interpersonal issues

• Coping and relapse prevention: increase self-control, risk management

Relapse and recidivism regarding paraphilic disorders?

• 75-95% improvement in sexual offenders

  1.      Course is typically chronic with high relapse

  2.      Those with poor outcomes are rapists, have multiple paraphilias

• Strongest risk for treatment failures

  1.      Multiple sexual victims

  2.      Unstable relationships, employment

  3.      Strong denial of sexual problem

  4.      Living with victim (incest)

Medical treatment for paraphilic disorders 🏥

• Medications decrease testosterone and sexual urges. Chemical castration used for most dangerous offenders 🧪

• Effectiveness: May decrease sexual desire, fantasy, arousal. High relapse/recidivism if medications stop though!

• Surgical castration, testes removed: lowers recidivism; only voluntary in Europe to reduce sentence

Gender dysphoria ♂ ♀ ❓

• Feels trapped in body of wrong sex; previously called transsexualism

• Seeks to become identity of opposite sex. Desired goal is NOT sexual!

Biological causes of gender dysphoria 🧬

• Prenatal or failed exposure to sexual hormones

• Natural hormonal variations, or result of medications

Psychological causes of gender dysphoria 🧠

• Gender identity: usually established by age 3

• Different societal responses to masculine girls VS feminine boys

Treatment for gender dysphoria 🏥

• not diagnosed/treated UNLESS it causes major distress/impairment

• Psychological intervention only gives short-term relief before sexual-reassignment surgery 🧠

  • Results of sexual reassignment surgery

  • Pre-conditions: psychological preparation and financial/social stability 💵

  • Before surgery, live as desired gender for several years! 💅