PSYC 2161: Chapter 14: Sexual Disorders & Gender Dysphoria
Case of William (“Peeping William”)
William’s story is used to show voyeuristic disorder: he gets sexual gratification from watching unsuspecting people undress or engage in sexual/private behavior.
Notice that his behavior started in adolescence, tied to guilt and fantasy, but escalated when he was lonely, rejected, and drinking.
This highlights how stress + low self-esteem + existing fantasies can push someone toward paraphilic behavior.
Paraphilic Disorders (DSM-5)
These are conditions where a person’s sexual attraction focuses on unusual objects, situations, or behaviors.
Examples:
Fetishistic disorder → sexual focus on non-living objects (like shoes, underwear).
Transvestic disorder → arousal from cross-dressing.
Pedophilic disorder → attraction to prepubescent children.
Exhibitionistic disorder → arousal from exposing genitals to strangers.
Voyeuristic disorder → arousal from spying on others (like William).
Frotteuristic disorder → rubbing against non-consenting people.
Masochism & Sadism → pleasure from pain (self or others).
Other / Unspecified → like zoophilia (animals) or necrophilia (corpses).
Key thing: Paraphilias become a disorder only when they cause distress, harm, or involve non-consenting people.
Sexual Dysfunctions (DSM-5)
These are problems with normal sexual response cycles (desire, arousal, orgasm, pain).
Examples:
Desire disorders → low sexual desire (male hypoactive, female interest/arousal).
Arousal disorders → erectile disorder, female arousal difficulties.
Orgasmic disorders → delayed ejaculation, premature ejaculation, inhibited orgasm.
Genito-pelvic pain/penetration disorder → pain during sex.
Substance/medication-induced sexual dysfunction → caused by drugs, alcohol, or meds.
How the Chapter is Structured
Gender identity disorder (old diagnosis, replaced in DSM-5 with gender dysphoria).
Paraphilias (atypical sexual attractions/behaviors).
Sexual dysfunctions (difficulties in “normal” sexual functioning).
✨ Simple Takeaway:
Chapter 14 covers when sexual behavior becomes disordered:
Paraphilias → unusual objects/behaviors.
Sexual dysfunctions → disruptions in normal sexual response.
Gender identity → controversial old category, now understood differently.
🌈 Gender Identity vs. Sexual Orientation
Gender identity = your internal sense of being male, female, both, or neither.
Sexual orientation = who you’re attracted to (men, women, both, etc.).
👉 Example: A man attracted to men is gay (orientation), but still identifies as male (identity).
🌀 What Was Gender Identity Disorder (GID)?
In DSM-IV, people with GID felt strongly (often since childhood) that they were the opposite sex.
Features included:
Dislike of same-sex clothing and activities.
Mismatch between anatomy (genitals, secondary sex traits) and their experienced gender.
Desire to pass as the opposite sex and sometimes undergo surgery.
Example case: A man who compulsively cross-dressed, felt conflict between his identity and his marriage, and struggled with shame.
🚨 Why GID Was Dropped in DSM-5
The label pathologized trans identities and stigmatized people for not identifying with their biological sex.
DSM-5 replaced it with Gender Dysphoria, which focuses on the distress someone feels from the mismatch between their assigned sex and gender identity—not the identity itself.
The shift = from “you are disordered” ➝ to “you may suffer distress society causes, and that’s what needs treatment.”
📚 Research & Support
Transgender well-being is influenced by affirmation (psychological, medical, social).
Study of 573 transgender women (Glynn et al., 2016):
Affirmation → ↑ self-esteem, ↓ depression.
BUT suicide risk was still unrelated, showing distress remains complex.
Distress is often tied to oppression, discrimination, and violence.
Guidelines & Practice
APA 2015 Guidelines: psychologists should practice culturally competent, trans-affirmative care.
Singh & Dickey (2016/2017): push for affirmative practice → therapy that:
Supports clients’ identities.
Considers multiple social factors (e.g., race, gender, class).
Helps reduce inequities and barriers.
✨ Key Takeaway
Old term GID → pathologized identity.
New term Gender Dysphoria → focuses on distress, not identity.
Supportive, affirming environments improve mental health for trans people.
Therapists are encouraged to provide respectful, inclusive, and affirming care.
🧑🤝🧑 The Joan/John Case (David Reimer)
Background: Twin boy, botched circumcision destroyed penis.
Dr. John Money suggested raising him as a girl → “Joan.”
Parents followed plan: castration, estrogen therapy, feminine upbringing.
Outcome:
Despite upbringing, Joan consistently showed boyish behaviors (ripped dresses, masculine play).
At 14, rejected female role → became John again.
Took male hormones, had surgeries (breast removal, artificial penis).
Married at 25.
Tragic later life: depression, brother’s death, marital separation → David died by suicide at 38.
Lesson:
Strong biological basis for gender identity. Environment alone couldn’t override innate identity.
Case changed medical policies → more cautious about sex reassignment in children.
🇨🇦 Contrast Case – Canadian Reassignment
Another boy lost penis after circumcision burn → reassigned female.
At 26, continued female identity, but:
Bisexual orientation.
Masculine interests & male-dominated occupation.
Suggests: biology still influences behavior, but environment may stabilize identity for some.
🛠 Therapies for Gender Identity Issues
1. Body Alterations
Usually start with 6–12 months psychotherapy.
Options:
Cosmetic surgery (e.g., chin/Adam’s apple reduction).
Hormones: estrogen (M→F), testosterone (F→M).
Electrolysis for facial hair removal.
Some pursue sex-reassignment surgery (first famous case: Christine Jorgensen, 1952).
2. Psychological Interventions
Focus on reducing distress, anxiety, and depression.
Help clients explore identity, relationships, and coping strategies.
Increasing emphasis on affirmative therapy: supporting the person’s experienced identity.
✨ Key Takeaways
David Reimer case = powerful evidence for biological roots of gender identity.
Canadian case shows some role for environment, but biology still leaves a mark.
Treatment approaches:
Support body alignment with identity (hormones, surgery).
Or help client manage distress psychologically.
Modern focus: affirmation, not pathologization → helping people live authentically.
⚖ Sex-Reassignment Surgery – Outcomes & Controversy
🔴 Early Controversy
Meyer & Reter (1979):
Found no significant improvement in social functioning after surgery.
This study was so influential that it led to the shutdown of Johns Hopkins’ sex-reassignment program, which at the time was the biggest in the U.S.
🟢 More Positive Findings
Green & Fleming (1990) review:
Looked at outcome studies (1979–1989).
Female → Male surgeries: ~97% satisfactory.
Male → Female surgeries: ~87% satisfactory.
✅ Factors predicting good outcomes:
Emotional stability.
Successfully living in new gender role ≥ 1 year before surgery.
Realistic expectations about surgery.
Psychotherapy in a structured gender identity program.
🟣 More Recent Studies
Lawrence (2003):
Study of 232 M→F transsexuals → none regretted surgery.
Dissatisfaction (when present) came from physical outcomes (e.g., appearance), not from the decision itself.
Denmark study (Simonsen et al., 2016):
Looked long-term.
Overall, little psychological change post-surgery.
Both M→F and F→M showed similar patterns.
❗ About 25% still had diagnosable psychiatric issues even after surgery.
✨ Key Takeaway
Surgery often helps align body with gender identity and reduces distress.
Success rates are high, especially when clients are stable, well-prepared, and supported.
BUT → Surgery is not a cure-all. Many still struggle with psychiatric issues post-op, showing that support and therapy are critical even after transition.
🌈 Paraphilias (Overview)
Paraphilias = sexual attractions to unusual objects or activities (deviation in attraction).
Must last 6+ months and cause distress or impairment to count as a disorder.
Many people have occasional fantasies (like voyeurism), but not all meet disorder criteria.
👉 DSM-5 draws a distinction:
Paraphilia = unusual interest (not always harmful).
Paraphilic disorder = when it causes distress OR harms/risk to others.
Most cases = men.
Many people with paraphilias show more than one type.
Some are linked to other disorders (schizophrenia, depression, personality disorders).
Legal consequences often apply since some involve non-consenting victims.
🧦 Fetishism
Definition: Reliance on inanimate objects (e.g., shoes, underwear) for arousal.
Common fetishes: shoes, stockings, rubber, fur, underwear.
Can involve masturbation, partner wearing fetish, or compulsive collection of items.
Starts by adolescence (sometimes earlier).
Often comorbid with pedophilia, sadism, masochism.
Example: Russell Williams case (Canadian colonel who escalated from underwear fetish to sadism & murder).
Key = compulsive, irresistible arousal tied to the object.
👗 Transvestic Disorder
Definition: Sexual arousal from cross-dressing, while still identifying as male.
Ranges from underwear under male clothes → full cross-dressing.
Term: Autogynephilia = arousal from imagining oneself as a woman (Blanchard).
Typically:
Starts in childhood/adolescence.
Almost always heterosexual men.
Often married; usually cross-dress in secret.
May overlap with gender dysphoria, but not the same.
Frequently comorbid with masochism.
✨ Key Takeaways
Not every unusual sexual interest = disorder. Only if distress or harm is present.
Fetishism = objects.
Transvestic disorder = cross-dressing for arousal.
Both can co-occur with other paraphilias.
👶 Pedophilia (Pedophilic Disorder in DSM-5)
Definition: Adults (≥16 yrs & ≥5 yrs older than child) who are sexually attracted to prepubescent children.
DSM-5 expanded understanding: some offenders target postpubescent but underage children too.
Not all pedophiles offend → surveys show 50%+ report no contact with children.
Much more common in men, though women can be offenders too.
Often comorbid with mood/anxiety disorders, substance abuse, and other paraphilias.
Can be heterosexual or homosexual in orientation.
🧑👩👦 Incest
Pedophilia sometimes overlaps with incest, but pedophilia excludes biological children in the DSM definition.
Historically, many high-profile cases have involved clergy (e.g., the Boston Globe Spotlight investigation).
Canadian cases → Antigonish, Chatham, Igloolik, St. John’s, Wilno, and Cornwall (large inquiry costing $53M identified 34 victims).
Today: professionals in Ontario are legally required to report suspected abuse.
🌐 The Internet’s Role
Internet has expanded pedophilic activity:
Child pornography access
Online grooming of victims
International networks (police often intervene).
Canadian example: Benjamin Levin (ex–Deputy Minister of Education) guilty of child-pornography charges.
Some cases escalate to extreme violence (e.g., Michael Briere).
📊 Research Findings
Child porn possession = stronger predictor of pedophilia than past child contact (Seto et al., 2006).
More frequent pornography use → higher recidivism risk.
Deviant content porn (violent, child-focused) = risk factor across offender levels.
Swedish study (Seto et al., 2015):
4.2% of 2,000 young men accessed child porn.
More likely to engage in sex with children + view violent porn.
Led to Internet-specific treatment programs for sex offenders.
✨ Key Takeaways
Pedophilia ≠ always offending, but risk increases with child porn use & deviant fantasies.
Legal + clinical consequences are major due to harm potential.
Internet has made detection and treatment both more urgent and more possible.
Social awareness grew massively after Spotlight and similar cases, shifting policies (mandatory reporting, specialized programs).
🔎 Offline vs. Online Offenders
Similarities: Both groups show higher rates of childhood physical & sexual abuse than general population.
Differences:
Online offenders = slightly younger, more victim empathy, but also greater sexual deviancy.
Offline offenders = more likely to act physically.
Conclusion: Online offenders may have more self-control and barriers to acting on extreme urges.
⚖ Parole & Restrictions
Convicted pedophiles often face restricted Internet access after parole.
Example: Robert Noyes (BC teacher & principal) → convicted for ~600 assaults, 65 victims. Declared a dangerous offender but still given parole with strict conditions.
🌐 Internet & Pedophilia Research
Researchers now conduct anonymous online studies → encourages more candid responses than face-to-face (Seto, 2004).
Internet is both a risk factor (child pornography, grooming) and a research tool.
🇨🇦 High-Profile Canadian Cases
Maple Leaf Gardens Scandal: ~90 victims abused by staff (e.g., Gordon Stuckless).
Survivor Martin Kruze later died by suicide after what he saw as a lenient sentence for Stuckless.
Inspired public awareness of CSA in Canadian sports.
Sheldon Kennedy (former NHL player) revealed abuse by coach Graham James in 1997.
Karl Toft (Kingsclear Facility, NB): abused 150+ children over decades; convicted of buggery, bestiality, & sexual assault.
Initially paroled in 2001, but public backlash sent him back to a secure psychiatric facility.
🧠 Patterns of Abuse
Most molestations = not overtly violent, but manipulation, threats, or intimidation are common.
Some sadistic/psychopathic offenders = child rapists, inflict deliberate harm.
University of Ottawa research: homicidal child molesters show stronger arousal to violent child assault stimuli compared to non-homicidal molesters.
👨👩👧 Incest
Definition: sexual relations between close relatives (siblings, parent-child).
Most common = brother–sister; next most common = father–daughter.
Quebec study: brother–sister incest caused just as much distress as father–daughter; also higher penetration rates.
Incest taboo = near-universal (evolutionary reason: recessive genes → birth defects).
Family patterns: patriarchal, traditional, emotionally distant parents, often absent/disabled mothers → less protection.
📖 Incest vs. Pedophilia (DSM-5 distinction)
Incest: within family; victims older (often teens).
Pedophilia: outside family; victims usually prepubescent.
DSM-5 dropped incest as a subtype of pedophilia.
🧒 Child Sexual Abuse (CSA) in Canada
Statistics (1999 survey):
62% of sexual offence victims = under 18.
30% = under 12.
Majority = female, victimized by someone they know.
Family = 28% of cases.
Law: mandatory reporting of suspected abuse in Canada.
✨ Key Takeaways
Both online & offline offenders share trauma backgrounds but differ in acting out.
CSA has had huge public cases in Canada (Maple Leaf Gardens, Kingsclear, Sheldon Kennedy).
Pedophilia ≠ incest: one involves unrelated children, the other family members.
Abuse is often non-violent but psychologically devastating, sometimes escalating to sadism.
Incest taboo = evolutionary protection (avoids harmful recessive gene expression).
CSA remains a major legal & clinical focus, with mandatory reporting laws.
🧠 Effects of Child Sexual Abuse (CSA)
Varied outcomes: Some kids show resilience, but most experience anxiety, depression, low self-esteem, and conduct issues.
Risk factors for worse outcomes:
Earlier onset of abuse
Longer duration
Dissociative symptoms
Lack of supportive family
Self-blame
Protective factors:
Approach coping (actively handling stress)
Extracurricular activities (boosts social support & confidence)
PTSD: CSA is a known trauma risk → many victims develop PTSD symptoms.
Revictimization: Survivors are more likely to experience sexual assault again in adulthood.
⚠ Long-Term Impacts
Mental health: Greater risk of depression, shame, and suicidal thoughts/attempts.
Interpersonal issues: Marital distress, relationship difficulties, sexual dysfunction.
Notable survivors: Drew Carey, Sheldon Kennedy, Théoren Fleury, R.A. Dickey have all shared CSA histories + suicidal struggles.
🛡 Prevention Strategies
School-based programs (e.g., ESPACE in Quebec):
Teach kids to recognize inappropriate behaviour.
Say NO firmly, resist, leave, and report.
Use stories, comics, films to model safe behaviours.
Side effect: boosts assertiveness & self-confidence (sometimes even too much with parents 😅).
Effectiveness: Raises awareness, increases likelihood of disclosure, but not always clear if kids actually apply the lessons long-term.
🇨🇦 National-Level Efforts
2010 National Think Tank (Western University) → called for a national CSA prevention strategy.
2011 Senate Report (“The Sexual Exploitation of Children in Canada”):
~9,000 reported sexual assaults against children per year.
80% victims are girls.
Aboriginal youth = particularly vulnerable.
Recommendations: national databank, a Children’s Commissioner, more victim/offender supports.
Internet safety strategy: Federal government has a National Strategy for Protection from Online Exploitation (funded & renewed).
✨ Key Takeaways
CSA has serious mental health, social, and risk outcomes, especially when onset is early and abuse is long-lasting.
Protective factors (support, coping, activities) help resilience.
Prevention = mostly school programs, but effectiveness varies.
Canada has recognized CSA as a national issue, with strategies in place, but challenges remain.
📊 Prevalence of Child Sexual Abuse (CSA) Among Students
Penn State scandal (2011): Jerry Sandusky convicted of CSA of eight boys → scandal raised student awareness of CSA.
Early study (Finkelhor, 1979):
19% of women and 9% of men reported CSA.
28% of abused women & 23% of abused men → incest.
Recent survey (Finkelhor et al., 2014) of 17-year-olds:
26.6% of girls, 5.1% of boys had lifetime CSA/sexual violence experience.
In 1/9 girls, perpetrators were exclusively adults.
Global meta-analysis (Stoltenborgh et al., 2011):
Sample: ~10 million people, 300+ studies.
Prevalence: 127 per 1,000 (≈12.7%).
Girls ≈ 2.5x more likely than boys.
Highest rates: girls in Australia, boys in Africa.
Meta-analysis comparing students vs. general population (Pereda et al., 2009):
7.9% of men, 19.7% of women (students).
General pop: 14.6% → Students: 13.9%.
→ About 1 in 7 students experienced CSA.
🎓 Consequences for Students
Mental health: Higher PTSD symptoms in CSA survivors (Canton-Cortés & Canton, 2010).
Academic outcomes: CSA history linked with higher dropout rates (Duncan, 2000).
Mediating factors:
Avoidant coping → worse outcomes.
Shame, self-blame, and interpersonal difficulties worsen adjustment.
Self-compassion improves resilience.
🔎 Research on Offenders
Studer et al. (2000):
22% of incest offenders = repeat offenders.
⅔ also had non-incest victims → overlap with pedophilia.
Rice & Harris (2002):
“Daughter-only” molesters = less psychopathic, but still deviant with notable recidivism risk.
Plethysmography studies (Freund, Marshall, etc.):
Extrafamilial molesters → aroused by nude children photos.
Incest offenders → more aroused by adult cues.
→ Shows some differences in sexual preference profiles.
Pornography:
Plays a role only if already predisposed (Seto et al., 2001).
Some pedophiles create fantasies from everyday, non-pornographic images (Howitt, 1995).
Risk factors for molestation:
Alcohol use, stress, negative mood, low self-esteem, poor social maturity.
Child molesters often socially isolated, low social skills.
Abused-abuser hypothesis: Many juvenile offenders were themselves sexually abused.
Screening Scale for Pedophilic Interests (SSPI) (Seto & Lalumière, 2001):
Reliable tool to identify pedophilic tendencies.
Predicts recidivism and deviant sexual arousal.
👦 Juvenile Offenders
Half of molestations committed by adolescent males.
Often come from chaotic, neglectful homes.
Common traits: poor academics, conduct disorder, substance abuse, depression, anxiety.
SAFE-T Program (Canada, Worling, 2001): Many juvenile molesters had CSA histories themselves → supports abused-abuser cycle.
👀 Voyeurism
Definition: Persistent preference for sexual gratification from watching others undress, shower, or engage in sexual acts (without consent).
If recorded → electronic voyeurism.
Orgasm: Usually via masturbation while peeping or recalling the event.
Features:
Risk/excitement of being caught is key.
Little/no direct contact with victims.
Often begins in adolescence.
Linked to social anxiety & poor social skills → peeping as substitute gratification.
Comorbidity: Often occurs with other paraphilias.
Legal issues: Usually charged with loitering, not “peeping.”
Sociocultural finding: In Denmark, access to porn reduced police reports of peeping (Kutchinsky, 1970). Internet porn may have similar effects.
👤 Exhibitionism
Definition: Sexual gratification from exposing one’s genitals to unsuspecting strangers (often women or children).
Onset: Typically adolescence.
Fantasy/Behavior:
Arousal from shocking or embarrassing victim.
Masturbation occurs during or after exposure.
Risk:
Ottawa study → 39% of exhibitionists committed further offences, 31% committed sexual/violent acts → not “benign.”
Hands-off vs. hands-on exhibitionists.
Prevalence:
Mainly men, often arrested for “indecent exposure.”
Very high comorbidity: voyeurism & frotteurism.
Psych findings:
Triggers = anxiety, restlessness, arousal.
Alberta plethysmograph study → more arousal to fully clothed women in non-sexual contexts → may misread social cues in “courtship phase.”
🚉 Frotteurism
Definition: Sexual gratification from rubbing/touching unsuspecting people (often genitals against thighs/buttocks).
Contexts: Crowded places (buses, sidewalks) → easy escape.
Onset: Adolescence.
Comorbidity: Often co-occurs with exhibitionism, voyeurism.
Prevalence/Impact:
Survey of 459 undergrads: 44% experienced exhibitionism or frotteurism.
Lasting negative impact:
~33% of frotteurism victims.
~14% of exhibitionism victims.
🔗 Sexual Sadism & Masochism
Sadism: Gratification from inflicting pain, humiliation, or suffering.
Masochism: Gratification from receiving pain, humiliation, submission.
Motivation:
Sadists: not just control → actual violence/aggression (Seto et al., 2012).
Masochists: humiliation, submission, “infantilism,” sensory deprivation, bondage.
Prevalence:
Both heterosexual & homosexual groups, but ~85% heterosexual.
Sadomasochism clubs: 20–30% female members.
5–10% of population tried mild S/M (e.g., spanking, blindfolding).
Dynamics: Sadists & masochists often pair together. Masochists outnumber sadists → some sex work caters to this.
Dangerous variants:
Hypoxyphilia → sexual arousal by oxygen deprivation.
Some sadists escalate to murder/mutilation (e.g., Paul Bernardo, Russell Williams).
Clinical concern:
Sadistic sex offenders → more violent crimes, serial murders, impersonation, body concealment.
Misdiagnosis is common → ⅔ of sadists misclassified as non-sadistic sex offenders.
🌀 Other Specified Paraphilic Disorders
Examples: necrophilia (sex with corpses), zoophilia/bestiality, telephone scatalogia (obscene calls), coprophilia (feces), klismaphilia (enemas), urophilia (urine).
Case evidence:
Canadian penitentiary case → man with bestiality + antisocial personality disorder killed a horse out of jealousy (Earls & Lalumière, 2002).
More cases show zoophilia may be more common than thought, across intelligence levels & locations.
Examples: “Possum,” a medical researcher with horse attraction; Nigerian man with schizophrenia + goat recidivism (Amoo et al., 2012).
Takeaway: these paraphilias can be highly dysfunctional and dangerous, not just “unusual preferences.”
🧠 Etiology of Paraphilias
Psychodynamic Perspective
Paraphilias = defensive mechanisms → protect ego from repressed fears/memories.
Seen as fixations at pregenital stages of psychosexual development.
Core idea: individuals are fearful of mature heterosexual/heterosocial relationships → rely on immature substitutes.
Examples:
Fetishist / pedophile → castration anxiety → adult sex too threatening.
Exhibitionist → reassures masculinity by exposing genitals.
Sadist → dominates others as defense.
Behavioural & Cognitive Perspectives
Classical conditioning theory: sexual arousal accidentally paired with unusual stimuli (e.g., leather boots → fetish).
Empirical support: weak, but inspired therapeutic techniques.
Multi-factor models: paraphilias result from multiple interacting factors:
Childhood histories: abuse, disturbed parent–child relationships.
Outcomes: insecure attachment, low self-esteem, loneliness, poor social skills.
CSA link: Childhood sexual abuse increases risk.
Female abuser → more recidivism risk.
Male abuser → more pedophilic interest (Nunes et al., 2013).
Other risk factors: hostility toward women, alcohol, negative emotions.
Cognitive distortions: e.g., voyeur thinks “if blinds are open, she wants to be watched.”
Operant conditioning: reinforcement of unconventionality (e.g., little boy praised for cross-dressing → transvestism).
Biological & Neuro Perspectives
Hormones: Androgens (testosterone) suspected, but evidence shows no consistently elevated levels in paraphilias.
Brain dysfunction: Some cases link temporal lobe dysfunction to sadism/exhibitionism.
Neuroimaging:
Erotic stimuli → reward system activity (hypothalamus, thalamus, amygdala).
Men = more activation than women.
Women’s genital responses = less specific, respond broadly (Chivers, 2010).
Sexual disorders findings:
Male-to-female transsexuals show female-like brain patterns during arousal (Gizewski et al., 2009).
Pedophiles show altered activity in frontal and temporal lobes + subcortical areas linked to addictive/uncontrolled behavior.
fMRI studies → nude children images strongly activate pedophiles’ brains, not controls (Ponseti et al., 2012).
Key takeaway: Paraphilias may involve different brain wiring, raising legal/ethical questions about responsibility and potential neurofeedback treatments.
🌱 Motivation Issues in Treatment
Many offenders are court-ordered into therapy → often low motivation.
Barriers: denial of problem, minimizing seriousness, victim-blaming, belief they can self-control.
Motivation strategies:
Therapist empathizes with reluctance (reduces defensiveness).
Point out benefits of treatment + consequences of refusing (harsher penalties, worse incarceration).
Paradoxical intervention: therapist doubts motivation, offender feels challenged to “prove” them wrong.
Psycho-physiological assessment reminder: sexual arousal patterns can be revealed regardless of denial.
Motivation is dynamic: increases in treatment, but drops again after release (Barrett et al., 2003).
🛠 Behavioural Techniques
Aversion therapy: pairing deviant stimulus (e.g., boot fetish, child photo) with shocks/emetics → reduces attraction.
Satiation: prolonged masturbation + verbalizing deviant fantasies → leads to boredom and reduced arousal.
Orgasmic reorientation: switching from deviant fantasy to conventional stimulus (e.g., nude woman) during masturbation → increases conventional arousal.
Mixed results; often still revert back to deviant fantasies.
Social skills training: builds confidence, communication, reduces reliance on deviant substitutes.
Alternative behavioural completion: offender imagines deviant scenario → changes ending (e.g., chooses control instead of exposing).
🧠 Cognitive Treatments
Focus: counter cognitive distortions (e.g., “kids aren’t harmed” → therapist reframes: harm is worse when younger).
Empathy training: offenders imagine victim’s perspective.
Relapse prevention: like substance abuse → learn triggers, coping strategies, preventing re-offense.
Broader CBT-based programs (institutional + outpatient):
Reduce recidivism more effectively than no treatment.
Better success for child molesters than rapists.
Cost-effective → even minimal success = public safety protection.
✨ Key takeaway:
Best outcomes = multi-modal approaches (behavioural + cognitive + social skills + relapse prevention).
Treatment is hard, motivation is unstable, but CBT shows promise, especially with child molesters.
⚖ Definitions
Forced rape = intercourse with an unwilling partner.
Statutory rape = intercourse with a minor below age of consent (in Canada = 14). Consent irrelevant → always illegal.
🔎 The Crime
Rape varies: some planned, some impulsive.
70% involve intoxication.
Motivations: control/domination, sexual drive (but many rapists can’t orgasm/erect).
Sadistic rape = physical injury (burning, foreign objects, mutilation). Sometimes includes murder.
Legally includes oral, anal, and vaginal penetration.
Acquaintance/Date Rape
Much more common than stranger rape (up to 3:1).
81% of assaults in Canada → offender known to victim.
University data:
~⅓ of dating women experienced coercion (Canada study).
15% sexually assaulted, 2% raped at Ontario universities.
Higher risk for 1st-year students.
US study: 9% of undergrads assaulted since starting college.
Victims often don’t report → privacy + lack of trust in authorities.
Campus scandals (e.g., Brock Turner, UBC) → led to laws requiring policies + task forces in Ontario & BC.
Victim Impact
Rape Trauma Syndrome: PTSD symptoms (nightmares, fear, phobias), depression, guilt, low self-esteem.
Additional concerns: unwanted pregnancy, STDs.
Negative outcomes worsened by insensitive responses from police/family.
Recovery improved by supportive relationships + therapy.
Date Rape Drugs
Rohypnol (odourless, tasteless) → causes blackout/amnesia.
Canadian study: 62% of women in suspected drug-facilitated assaults had total memory loss.
Calls for better toxicology screening.
👤 The Rapist
Heterogeneous group: psychopathic, insecure, authority abusers, teens, alcohol-disinhibited.
Common features: hostility toward women, past abuse/violence exposure.
Implicit beliefs (Beech, Ward, Fisher, 2006):
World is dangerous.
Women are dangerous.
Women = sex objects.
Male sex drive = uncontrollable.
Entitlement → can do what they want.
Traits: low social skills, low self-esteem, low empathy (may suppress empathy for victim specifically).
🧠 Therapy
For Rapists
Multi-dimensional programs in prison.
Components:
CBT → challenge distorted beliefs (“women want to be raped”).
Build empathy.
Anger management.
Improve self-esteem.
Substance abuse treatment.
Relapse prevention.
Sometimes use biological interventions (to lower sex drive).
Mixed effectiveness, but meta-analyses show some reduction in recidivism, especially if program completed.
Canadian Research (Recidivism)
Incest offenders → lowest reoffense rates.
Rapists & exhibitionists → highest reoffense rates.
Predictors: being young, single, high # of prior offences.
Antisocial personality disorder = strongest psychological predictor.
Effective treatment must target established risk factors (Table 14.2).
✨ Key takeaway:
Rape is less about sex than about power, control, and hostility toward women. Most victims know the offender. Treatment focuses on reshaping distorted beliefs, empathy, anger management, and relapse prevention, but prevention policies on campuses and survivor support are equally crucial.
⚖ Psychopathy & Sexual Recidivism
Psychopathy alone ≠ strong predictor of sexual recidivism.
Early Canadian study: men with psychopathy + deviant sexual arousal → reoffended faster & more often (Serin et al., 2001).
Later study: sexual deviance predicted sexual recidivism; psychopathy predicted non-sexual recidivism (Olver & Wong, 2006).
Meta-analysis (Hanson & Morton-Bourgon, 2005):
Sexual deviance → reliable predictor of sexual recidivism.
Anti-social orientation (incl. psychopathy) → predicted violent & general reoffending.
PCL-R (psychopathy test) → weak link to sexual recidivism overall.
Updated meta-analysis (Hawes et al., 2013):
Looked at PCL-R factors separately → found stronger link.
Best prediction = psychopathy + past sexual deviance together.
⚠ Extreme risk cases: Some individuals with both traits (psychopathy + sexual deviance) show severe, violent sex crimes (e.g., erotic violence syndrome case).
📊 Treatment Outcomes & Concerns
Mixed results in Canadian research:
Seto & Barbaree (1999): men who behaved “better” in group treatment (attending more, less disruptive) → paradoxically more likely to reoffend. Suggestion: psychopathic offenders may learn skills to manipulate victims.
Barbaree (2005) re-analysis → didn’t replicate this; treatment behaviour didn’t predict recidivism.
Overall:
Treated offenders → 11.1% recidivism.
Untreated offenders → 17.5% recidivism (Schmucker & Losel, 2008).
Effective treatments: CBT, behavioural methods, hormonal medication, castration.
Ineffective: purely non-behavioural treatments.
Open question: Do psychopathic offenders actually benefit from treatment? Current research = too limited to conclude.
🧠 Research Standards
CODC (2007) published guidelines for sex offender treatment research.
Goal: improve quality of outcome studies.
Many past studies = weak (program reviews, not rigorous experiments).
💡 Thinking Critically
Should sex offenders always receive treatment?
Would your opinion change if the offender is a psychopath (higher risk, manipulative)?
Community reactions: often drive offenders out after release → raises ethical questions:
Victim/public safety vs. offender’s right to privacy & rehabilitation.
How would you personally respond if a treated sex offender moved into your neighborhood?
🧾 Therapy for Rape Victims
Expanded support: rape crisis centres & hotlines across North America.
Therapy focuses on:
Victim’s ongoing relationships (friends, family, spouse).
Helping supporters manage their own emotional reactions.
Similar to PTSD treatment:
Exposure therapy → effective.
CBT → reduces PTSD symptoms, depression, guilt.
But ~⅓ drop out or still meet PTSD criteria post-treatment.
Cognitive Processing Therapy (CPT) (Resick & Schnicke, 1993):
12-session program combining exposure + cognitive restructuring.
Helps victims challenge self-blame and distorted trauma beliefs.
Uses assimilation & accommodation concepts (Piaget).
Proven to reduce guilt, shame, PTSD, and distorted thinking.
⚖ Legal & Reporting Issues
Many women don’t report rape because:
See it as private.
Fear reprisals.
Distrust of police sensitivity.
Convictions are rare:
BC study: only ⅓ of reported cases led to charges.
Only 1 in 10 charged cases led to conviction.
Medical forensic examination (MFE):
Can collect vital evidence (injuries, DNA).
Often stressful, but helps validate the victim’s experience.
✨ Key Takeaway:
Sexual deviance > psychopathy for predicting reoffense.
But both together = highest risk → extreme violence possible.
Treatment can reduce recidivism somewhat, but psychopathic offenders remain tricky.
For victims, therapy (especially CPT) is effective, but stigma, legal hurdles, and underreporting remain major barriers.
🌍 Changing Views of Sexual Problems
Past (19th–early 20th century):
Too much sex = “abnormal” → excess was the problem.
Now (contemporary view):
Too little sex or inhibited responses = “abnormal.”
💡 Takeaway: “Normal” depends on time & culture.
💑 Impact of Sexual Dysfunctions
Sexual problems don’t just affect the person → they affect the relationship.
Marriages/partnerships may suffer if one partner fears sex.
Sexuality often ties into self-concept (confidence, identity, closeness).
Severe dysfunctions can make people lose even basic tenderness/intimacy.
🔄 Human Sexual Response Cycle (Masters & Johnson + Kaplan)
Appetitive phase (Kaplan)
Sexual interest/desire + fantasies.
Excitement phase
Sexual pleasure + physiological changes.
Blood flow = erection in men, lubrication & swelling in women.
Orgasm phase
Peak sexual pleasure.
Men: ejaculation almost inevitable.
Women: vaginal contractions.
Both: muscle tension + pelvic thrusting.
Resolution phase
Relaxation & well-being after orgasm.
Men = refractory period (no new erection).
Women = can quickly respond again → multiple orgasms possible.
📊 Prevalence
Survey (3,000+ people):
43% of women & 31% of men reported dysfunction in past year.
Most = occasional & normal.
DSM-5 requires problem to be persistent, recurrent, & distressing for diagnosis.
Comorbidity is common → e.g., low desire often paired with another dysfunction.
🔥 Sexual Desire Disorders
Hypoactive sexual desire disorder:
Deficient/absent sexual fantasies or desire.
Sexual aversion disorder:
Strong avoidance of sexual contact.
Removed from DSM-5 (rare).
⚠ Diagnosis is tricky:
How much desire is “enough”? Often reflects dissatisfaction of a partner.
📖 Case example:
Woman enjoyed sex → husband admitted affair → she developed aversion (saw his touch as rape, avoided all sex).
🧾 Causes of Low Desire
Psychological/relational:
Poor communication in relationship.
Anger at partner (especially powerful in men).
Everyday stress.
Past trauma (rape, CSA).
Biological/medical:
Depression.
Medications (antihypertensives, tranquilizers).
Low testosterone in men.
Other factors:
Religious orthodoxy.
Fear of pregnancy, loss of control, or STIs.
Lack of attraction (e.g., poor hygiene in partner).
Cultural differences: e.g., American men reported more hypoactive desire than British men.
✨ Quick Recap:
Sexual dysfunctions = disruptions in the normal response cycle.
They affect relationships & identity.
Low sexual desire can come from stress, anger, trauma, biological factors, or relational issues.
🌊 Sexual Arousal Disorders
Definition: Desire is present, but the body doesn’t respond properly (arousal fails).
Types:
Female sexual interest/arousal disorder (old term = frigidity).
Male erectile disorder (old term = impotence).
❌ Old terms were derogatory (frigidity = “cold,” impotence = “not manly”). Newer language avoids blaming the individual.
Women:
Inadequate vaginal lubrication for comfortable intercourse.
Prevalence: Meta-analysis → 40.9% overall female sexual dysfunction; hypoactive desire most common (28.2%).
Men:
Can’t get/maintain erection.
Prevalence: 3–9% (increases with age).
Linked to premature ejaculation, anxiety, depression, age.
Biological + psychological causes:
Diseases (diabetes, kidney disease, alcoholism).
Medications (Thorazine, Prozac, antihypertensives).
Psychological factors (low self-efficacy, depression, performance anxiety).
⚡ Hypersexual Disorder (not in DSM-5)
Described as compulsive or addictive sexual behaviour.
Proposed as “sexual desire disorder with impulsivity.”
Reasons for exclusion: fear of pathologizing normal sex drive + legal misuse.
Still recognized in ICD-10.
Surveys: 1–2% of men report compulsive sex that impairs life.
Famous cases: Tiger Woods, Russell Brand, David Duchovny.
🔥 Orgasmic Disorders
Female Orgasmic Disorder
Formerly: “inhibited female orgasm.”
Definition: No orgasm after adequate arousal.
Prevalence: 16–46% (2nd most common female problem after low desire).
Many women fake orgasms (up to 61%).
Causes:
Lack of masturbation history → less likely to orgasm later.
Low knowledge of anatomy.
Different orgasm thresholds (some need prolonged clitoral stimulation).
Alcohol use.
Fear of losing control (“la petite mort” = “the little death”).
Biological: sympathetic nervous system differences (some women’s arousal shuts down under stress).
Male Orgasmic Disorders
Delayed Ejaculation (rare, 3–8%).
Causes: fear of pregnancy, hostility, repressed anger, spinal injury, medications.
Premature Ejaculation (PE)
Most common male dysfunction.
Occurs before or shortly after penetration.
Prevalence: 16–27% of Canadian men (common worldwide).
Causes:
Anxiety, sensitivity of penis, long abstinence periods.
Learning history (hurried sex due to fear of being caught).
Impact: negative for men and partners (lower quality of life, relationship strain).
😣 Sexual Pain Disorders (DSM-5: Genito-pelvic pain/penetration disorder)
Symptoms (any one qualifies if distressing):
Difficulty with vaginal penetration.
Pain during intercourse (dyspareunia).
Linked with low desire, low arousal, dissatisfaction.
Fear/anxiety about pain.
Involuntary vaginal spasms (vaginismus).
Penetration impossible but normal arousal/orgasm possible otherwise.
❗ Hard to separate dyspareunia vs vaginismus → both involve penetration issues.
🧠 General Theories of Sexual Dysfunctions
1. Historical Views
1800s: Problems = result of excessive masturbation or “too much sex.”
Belief: wasted sexual energy damaged ability to function later.
Prevention methods: metal mittens for kids, bland diets (Kellogg’s cornflakes, graham crackers).
2. Psychoanalytic Views
Dysfunction = symptom of repressed conflict.
Example:
Rapid ejaculation = unconscious hostility toward women.
Vaginismus = hostility toward men (from trauma/abuse).
3. Masters & Johnson (1970)
Famous book: Human Sexual Inadequacy.
Conceptualized dysfunctions with a two-tier model (current vs historical causes).
Focus: sexual problems are learned behaviours + anxiety-driven cycles, not just deep personality flaws.
✨ Quick Recap (Flashcard-Style)
Arousal disorders: Women = lack of lubrication; Men = erectile failure.
Hypersexual disorder: not in DSM-5, but ICD-10 recognizes compulsive sex.
Orgasmic disorders: Women = difficulty/orgasm absence (16–46%); Men = delayed or premature ejaculation (PE most common).
Pain disorders: Dyspareunia + vaginismus under new combined DSM-5 category.
Theories: Victorian “excess,” psychoanalytic repression, Masters & Johnson’s behavioural cycle model.
🌟 Current Causes (Proximal)
Performance fears: Worrying too much about “doing well” in sex.
Spectator role: Watching yourself from the outside instead of experiencing pleasure.
⚠ Problem: We don’t know if these cause dysfunctions or just maintain them.
Example: Man with ED → anxiety about erection → failure again (a cycle).
📜 Historical Causes (Masters & Johnson)
Religious orthodoxy – Conservative upbringing, negative messages about sex.
Psychosexual trauma – e.g., rape, humiliation, negative early encounters.
Homosexual inclination – Reduced pleasure when engaging in non-preferred orientation sex.
Inadequate counselling – Harmful advice from professionals/clerics.
Alcohol – “Provokes desire but takes away performance” (Macbeth!).
Biological factors – Illnesses, hormones, drugs (reviewed earlier).
Socio-cultural factors – Gender roles, class expectations, feminist movement has shifted but inequalities persist.
🔍 Other Views
Dysfunction not always isolated → often tied to relationship conflict.
Dual problems: sexual + interpersonal.
Example: anger, resentment, poor communication.
Knowledge/skill deficits: Some people lack sexual education/experience.
Response anxiety: Anxiety about not being aroused can itself block arousal.
Poor communication: Not expressing likes/dislikes → misinterpretation → dissatisfaction.
✨ Protective factors: supportive partner, strong social network, therapy.
🛠 Therapies for Sexual Dysfunctions
Problem: 75% don’t seek help (survey of 5 nations, including Canada).
Pioneers: Masters & Johnson (1970) → started modern sex therapy.
Aim: Reduce performance fears, stop spectator role.
Both partners always involved (“no such thing as an uninvolved partner”).
🌸 Sensate Focus (their big therapy innovation)
Couples touch each other without intercourse → focus on sensations, not performance.
First step: rebuild intimacy, remove pressure.
Later: guided, explicit techniques to improve sexual response.
🌈 Later Additions
CBT-based strategies → especially useful for pain disorders.
Address sexual value systems, beliefs, communication.
Can blend psychodynamic + behavioural methods.
Evidence: CBT effective for women’s sexual pain (LoFrisco, 2011).
✨ Study Hack (Flashcards)
Q: What are the 2 proximal causes? → Performance fears + spectator role.
Q: Name 3 historical causes. → Religious orthodoxy, psychosexual trauma, alcohol use.
Q: What’s response anxiety? → Fear of not being aroused → inhibits arousal.
Q: Key Masters & Johnson therapy? → Sensate focus.
Q: % of people not seeking help? → 75%.
🌿 Anxiety Reduction
Systematic desensitization (Wolpe): Gradual exposure to anxiety-provoking aspects of sex.
In vivo desensitization: Real-life exposure paired with relaxation training.
→ Especially effective when combined with skills training.
✋ Directed Masturbation (LoPiccolo & Lobitz, 1972)
Designed for female orgasmic disorder.
Steps:
Examine nude body, genitals (with diagrams).
Touch/self-explore to locate pleasure zones.
Add erotic fantasies → increase intensity.
Use vibrator if orgasm hasn’t occurred.
Partner joins (watching, assisting, eventually intercourse with clitoral stimulation).
✅ Evidence: significantly improves treatment outcomes (O’Donohue et al., 1997).
🧠 Changing Attitudes & Thoughts
Sensory awareness procedures: Focus on pleasant sensations.
Rational-emotive behaviour therapy: Replace “musturbation” (“I must perform”) with flexible, self-accepting thoughts.
Kaplan’s ideas (1997):
Use erotic fantasies.
Courtship/dating assignments (e.g., romantic weekend).
Reduce pressure & increase sexual attractiveness.
💬 Skills & Communication Training
Use written materials, videos, demonstrations.
Teach couples to communicate likes/dislikes.
Communication → reduces anxiety, builds intimacy.
Difficult because tension in general relationship often bleeds into sexual issues.
❤ Couples Therapy
Sexual problems often embedded in relationship distress.
Couples may need non-sexual communication training + relational skills.
Important: incorporate the partner in ED treatment → improves adherence & long-term outcomes (Dean et al., 2008).
Problem: men often seek ED treatment alone, which is less effective.
⚕ Medical & Physical Procedures
Important to rule out somatic causes (esp. ED & dyspareunia).
Hormone treatments: Estrogen for postmenopausal women → reduces vaginal pain/lubrication issues.
Medications:
Antidepressants (for depression + low drive).
Tranquilizers (adjunct to anxiety reduction) – but may worsen sexual function.
Surgical options:
Penile implants (silicone rods, pumps).
Vascular surgery (mixed results).
Drugs (Viagra, since 1998):
Improves ED in ~70% men.
Side effects: headaches, flushing, indigestion, visual disturbances.
Risky for men with cardiovascular disease.
🌍 Broader Perspective
Viagra and medicalization risk → shifting normal aging into “pathology.”
Experts argue for biopsychosocial model (Althof et al., 2005):
Integrates physical, psychological, interpersonal factors.
No single intervention is enough.
Must treat sex dysfunctions as interpersonal + biopsychosocial problems.
✨ Flashcard-Style Quickies
Q: What therapy is used for female orgasmic disorder? → Directed masturbation.
Q: What does “musturbation” mean? → Rigid “I must” thoughts about sex (Ellis).
Q: Why is partner involvement key in ED treatment? → Improves adherence + long-term outcomes.
Q: What’s the risk of relying only on Viagra? → Ignores psychological/interpersonal aspects; pathologizes aging.
Q: What model is recommended by experts? → Biopsychosocial model.