Week 7 - Sexual and Gender Identity Disorders

Sexual Response Cycle

• Desire

• Arousal

• Orgasm

Each are associated with specific sexual dysfunctions — but to be a classified as a dysfunction it must be distressing

Sexual Dysfunctions and Gender

Most sexual dysfunctions have parallel versions for male and females
Except for arousal disorders (erectile dysfunction) and genito-pelvic pain/ penetration disorder

Classifications of Sexual Dysfunctions

• Generalized or situational

• Lifelong of Acquired

Generalized

Not limited to specific situations, stimulations or partners

Situational

Only in certain situations, stimulation or with specific partners Li

Lifelong

Present since sexual activity began

Acquired

Beginning after normal sexual activity

Desire

Sexual urges in response to sexual cues or fantasies 

Arousal

Subjective sense of sexual pleasure & physiological signs of sexual arousal

Orgasm

In males, feelings of inevitability of ejaculation, followed by ejaculation; in females, contractions of the walls of the lower third of the vagina

Male Hpoactive Sexual Desire Disorder

Prevalence: 5% and increases with age
Little or no desire to engage in sexual activity

Decreased frequency of masturbation, sexual fantasies & intercourse

Symptoms persist for at least 6 months, cause clinically significant distress and are not better explained by another mental disorder, severe relationships issues (DV), stressors, substances or medical conditions

Female Sexual Interest/ Arousal Disorder

Prevalence: 22% and decreases with age
Little or no desire and/ or interest in engaging in sexual activities + reduced arousal ability

Symptoms persist for at least 6 months, cause clinically significant distress and are not better explained by another mental disorder, severe relationships issues (DV), stressors, substances or medical conditions

Male Erectile Disorder

Man having sexual desire but not being able to achieve or maintain an erection
Prevalence: 5% (18-59) and increasing rapidly after 60

Female Sexual Arousal Disorder

Difficulty achieving and maintaining adequate lubrication
14% in women (?)

Orgasm Disorders

Orgasm occurs at inappropriate time or not at all

Delayed Ejaculation

8% report delayed or no ejaculation during sexual interaction despite desire and arousal

Premature Ejaculation

Recurrent pattern of ejaculating before man or his partner wishes, ~1 minute
Most prevalent male sexual dysfunction - 21% but declines with age

Symptoms persists for 6+ months & occur in 75-100% of sexual encounters (situational, or generalised contexts)

Significant distress to individuals & not better explained by another mental disorder, relationship issues, stressors, substances or medical conditions. 

Female Orgasmic Disorder

Adequate desire and arousal
Marked delay or infrequency or absence of orgasm, markedly reduced intensity or orgasmic sensations

Symptoms persists for 6+ months & occur in 75-100% of sexual encounters (situational, or generalised contexts)

Significant distress to individuals and not better explained by another mental disorder, relationship issues, stressors, substances or medical conditions.

Sexual Pain Disorders

Experienced by women

• Vaginismus

• Vulvodynia

Vaginismus

VulvodyniaInvoluntary pelvic spasms during penetration; affects about 6% of women 

• Feeling of ripping, burning, or tearing

Vulvodynia (Genito-pelvic/ penetration disorders)

Chronic pain around vulva (burning, rawness or stinging) associated w/ pelvic muscle tension especially during intercourse 

• often linked to anxiety, depression & past trauma but no clear physical cause (at least 3 months)

Methods of Assessing Sexual Behavior

• Interviews

• Medical Examinations

• Psychophysiological Assessments

Interviews

Clinician must show comfort to client and must be ready to use use vernacular

• Common topics include: sexual interest, fantasies, frequency of intercourse/ masturbation, sexual difficulties

• Address relationship between physical and psychological health

• Partners included where possible

Medical Examinations

• Inquire about medical conditions & medications that may be affecting sexual functions

• Recent surgeries or medications (hypertensions, prozac) can disrupt sexual arousal

Psychophysiological Assessments

• Exposure to erotic material

• Males - Penile Strain Gauge   ||   Women -  Vaginal photoplethysmograph (VPG)

• Measure physical arousal, but often differ from self-reported arousal

Biological Contributions to Sexual Dysfunctions

• Physical Disease: affects sensation or blood flow to lower region

  • diabetes & kidney disease (neurological) reduce genital sensitivity

  • Vascular disease: affect erections & vaginal engorgement

• Prescription Medications: affecting blood flow or sexual desire/ arousal

  • Antidepressants (SSRIs), blood pressure medications

  • Alcohol & drugs: suppress physical responses and sexual desire/ arousal

Psychological Contributions to Sexual Dysfunctions

Tied to Performance of anxiety:

• Arousal

• Cognitive Processes

• Negative Affect

Arousal and Sexual Dysfunction

Dysfunctional people often report decreased sexual arousal; anxiety & distraction

Cognitive Processes

Pessimistic thinking errors - often expect negative outcomes and become distracted by these negative thoughts, hindering arousal

Negative Affect

When faced with possible sexual encounter - expect the worst - underreport arousal levels, lacking awareness of their physical state; perceived lack of control

Social and Cultural Contributions

• Negative scripts in childhood learning sexuality is negative/ threatening - erotophobia

• Negative/ traumatic sexual events (childhood) increase risk of sexual dysfunction 

• Low self-esteem/ confidence 

• Poor communication & discomfort in discussing sexual needs 

Psychosocial Intervention (Masters & Johnson)

Educate about sexual functioning, myths, enhance and reduce performance anxiety using method like:

• Sensate focusing & non-demand pleasuring - explore each other's bodies w/o genital touching, gradually introducing genital pleasuring  w/o pressure of orgasm

Treatment for Erectile Dysfunction

Squeeze technique

Treatment for Orgasmic Disorder

explicit training in masturbation & use of vibrators

Treatment of vulvodynia

pelvic floor therapy, CBT and pain management

Treatment for Vaginismus

Dilators & gradually penis during genital & non-genital pleasuring

Medical Interventions for Sexual Dysfunction

Mainly for Erectile dysfunction 

• Oral tablets (viagra, levitra & cialis) → blood flow to penis

  • Effectiveness = persons anxiety - combine w/ CBT = improved satisfaction 

• Vasodilating drug injections; inject into penis for quick erections 

• Surgery - penile prosthesis or implants 

• Vacuum device therapy: draw blood to penis

Paraphillic Disorder

• Recurrent, intense sexual urges involving unusual objects, activities or situations, which cause clinically significant distress or impairment. 

  • DSM-5 makes it clear that Paraphilia isn’t a disorder unless there's distress/ harm

• Nature of paraphilias 

Fetishistic Disorder

Sexual attraction = nonliving objects (intimate object | tactile stimulation)

Voyeuristic Disorder

Observing to be aroused, unsuspecting individual undressing/ naked

Exhibitionistic Disorder

Sexual arousal & gratification in exposing genitals to unsuspecting strangers

Frotteuristic Disorder

Touching/ rubbing against a non consenting person in public 

Transvestic Disorder

Sexual arousal is strongly associated w/the act of (/ fantasies of) dressing in clothes of the opposite sex 

Sexual Sadism

Associated with inflicting pain or humiliation to get off

Sexual Masochism

Associated with suffering pain or humiliation to get off

Pedophillic Disorder

Attraction to children (according to textbook; up to 13 y/o)

Incest

Sexual attraction to family member

Causes of Paraphilia

Childhood trauma or significant childhood experiences

Causes are unclear; limited research; unlikely to be single factor 

• Early inappropriate sexual associations/ experiences (accidental/ vicarious)

• Possible inadequate development of consensual adult arousal patterns 

• Possible inadequate development of appropriate social skills for relating to adults 

  • Inappropriate sexual fantasies repeatedly associated w/ masturbatory activities & strongly reinforced 

  • Repeated attempts to inhibit undesired arousal & behaviour resulting in (paradoxical) increased in paraphilic thoughts, fantasies, and behaviour

Prognosis for Paraphilia

For most paraphilic disorders good; 70-98% improve 

• Poorest outcomes for rapists/ multiple paraphilia’s ⇒ high relapse rates & chronic 

• Depends on motivations 

Covert Extinction

Behavioral intervention for paraphilia involving using imagination to associated unwanted arousal with the worst outcomes/ consequences possible

Orgasmic Reconditioning

Behavioral Intervention for paraphilia involving masturbation to “usual thoughts” and when reaching orgasm shift thinking to appropriate thoughts/ stimuli — gradual shifts in preferences

Other psychological interventions for paraphilia

• Interpersonal therapy or Family/ Marital therapy

• Coping and Relapse prevention 

  • CBT intervention: coping skills to teach patients to manage urges early

Medication for paraphilia

• Anti Androgen medication 

  • Chemical castration - eliminates sexual desire & fantasy by reducing testosterone dramatically (Cyproterone acetate) 

• Efficacy 

  • Greatly reduce desire, fantasy, arousal – High relapse when discontinued 

Gender Dysphoria

Person's assigned sex at birth isn’t consistent w/ the person's sense of who they really are or with their experienced gender 

• Feels trapped in the body of the wrong sex

• Associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

• In extreme cases reject assigned set & wish to change it 

• Assume identity of the desire sex 
  

Biological Contributions to Gender Dysphoria

• Unclear, but likely genetic contributions; 62-70% from twin studies 

• Hormones - Slightly higher levels of testosterone/ estrogen at certain critical periods of development might masculinize a female foetus or feminize a male foetus ⇒ Brain structure differences?

Development of Gender Dysphoria

• Gender Identity seems to solidify between 18 months a 3 y/o

• Gender non-conforming behaviour in children doesn’t always lead to gender dysphoria; many grow up to be heterosexual or have same-sex attraction

• Parental influence - boys & excessive attention from mum/ lack of male playmates may contribute to nonconformity– discouraged by family

Treatment of Gender nonconformity in children

• Work w/ child & caregivers to lessen gender dysphoria & decrease cross-gender behaviours 

• “Watchful waiting” 

• Actively affirming & encouraging cross-gender identification

Treatment

• Surgery is only recommended after living as the identified gender for 1-2 years & meeting psychological, social, and financial stability criteria.

  • Gender affirmation (aka reassignment) as a treatment 

    • Most invasive 

      • Undergo hormone therapy 

      • Psychotherapy if deemed necessary by psychotherapist 

      • Demonstrated knowledge of logistics and risks of surgery 

      • Demonstrable progress in dealing with work, family and interpersonal issues resulting in better state of mental health