Paraphilic Disorders, Sexual Dysfunctions, and Gender Dysphoria
Paraphilic Disorders
Paraphilias are characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving nonhuman objects, children or other nonconsenting persons, or the suffering or humiliation of self or partner. A paraphilic disorder is diagnosed when a paraphilia causes distress and impairment. The ICD-11 limits paraphilic disorders to those that involve sexual arousal patterns focused on nonconsenting others or associated with substantial distress or direct risk of injury or death.
Types of Paraphilic Disorders
Pedophilic disorder: Sexual arousal from the presence of children or adolescents.
Exhibitionistic disorder: Sexual arousal from exposing the genitals to unsuspecting strangers. Begins early in adulthood, may involve suicidal thoughts, and is often comorbid with depression and substance abuse. Victims can be of any age and report feelings of disgust and victimization.
Voyeuristic disorder: Sexual pleasure from observing nudity or sexual activity of others. It is the most common paraphilia, with a higher prevalence in men and is related to exhibitionism.
Fetishistic disorder: Sexual arousal from an object (fetishism) or from a part of the body (partialism). Arousal depends on the object rather than sexual intimacy with a partner. The attraction must be recurrent and intense for at least 6 months and cause impairment and distress for diagnosis. Partnered fetishistic activity may be more sexually satisfying than solitary activity.
Frotteuristic disorder: Sexual urges about and sexually arousing fantasies of rubbing against or fondling a nonconsenting person. Victims feel violated and avoid crowds. From French frotter (“to rub”).
Sexual masochism disorder: Sexual arousal from being made to suffer (masochism). People are sexually aroused by being beaten, bound, or otherwise made to suffer. The term masochism describes the act of seeking pleasure from being in pain
Sexual sadism disorder: Sexual arousal from inflicting suffering on another person (sadism). DSM-5-TR does not classify bondage, domination, and sadomasochism (BDSM) as a disorder in and of itself. Unlike everyday sadism, which is the tendency to derive pleasure from watching or causing harm, specific focus is on sexuality and not particularly linked to antisocial tendencies. People with this disorder do not often seek out treatment and do not feel the need to change.
Transvestic disorder: Cross-dressing associated with intense distress or impairment. Commonly displayed by cisgender men. The ICD-11 eliminated this diagnosis entirely.
Diagnosis of paraphilia must reflect symptoms of people who are psychologically dependent on the particular form or target of their desire and otherwise cannot experience sexual arousal. A person’s “nonnormative” sexual behavior is not pathological in and of itself. Having a paraphilic disorder is not illegal, but acting on paraphilic urges may be.
Paraphilic disorders begin in adolescence and tend to be chronic. More prevalent in men than women and individuals are at risk for other psychological disorders such as anxiety, depressive, bipolar, sleep, and psychotic disorders.
Viewing prevalence in terms of victims, sexual assault of children reported at 57,000 per year, with one third below the age of 12.
Theories and Treatment
At a subclinical level there appear to be linkages among many paraphilic disorders, with a general correspondence to the degree of an individual’s sex drive. It can be viewed as a product of biopsychosocial factors.
Biological perspectives: Involve a combination of influences including genetic, hormonal, and sensory factors in interaction with cognitive, cultural, and contextual influences. Treatments include Luteinizing hormone-release hormone (LHRH)—medications that suppress the production of testosterone along with psychotherapeutic medications to alter neurotransmitter levels. Emphasis on altered genetic, hormonal, and sensory factors.
Psychological perspectives: The majority of the psychological literature on paraphilic disorders focuses on pedophilic disorder. Cognitive behavioral perspective is useful in helping clients recognize their distortions and denial. Therapy with emphasis on changing behaviors. Another focus is on clinicians who may express prejudice, pathologizing attitudes, and other approaches that regard clients negatively.
Sociocultural perspectives: Widespread availability of pornography including sexual violence can be regarded based on “sexual script theory.” Emphasizes ways that individuals gain understanding of sexuality through resources in the environment. Normalizing sexual violence creates cultural environment impacting users, normalizing behaviors that involve potential victims, particularly women. Research has indicated blaming the female victim and absolving the male perpetrator, supporting the view of a rape- supportive culture as shaping the perceptions of sexual violence.
Sexual Dysfunctions
Sexual dysfunction is a marked divergence in an individual’s sexual response that is accompanied by feelings of significant distress or impairment. Clinicians must be unable to attribute to psychological disorder, effects of substance use, or a general medical condition.
DSM-5-TR distinguishes between sexual dysfunctions that are lifelong, and those that are acquired, and between those that are generalized and those that are situational. Physiological and behavioral factors and chronic health conditions are strongly related to the risk of developing sexual disorders, Including diabetes, cardiovascular disease, other genitourinary diseases, psychological disorders, other chronic diseases, substance use, and smoking.
Sexual dysfunctions have historically been framed in terms of assigned sex and heterosexual relationships, but researchers are beginning to examine same-sex relationships and starting to explore sexual dysfunction in transgender individuals who have had gender-affirming medical procedures.
Arousal Disorders
Male hypoactive sexual desire disorder: Sexual dysfunction in which the individual has an atypically low level of interest in sexual activities, including few or no sexual fantasies.
Female sexual interest/arousal disorder: Persistent or recurrent inability to attain or maintain normal physiological and psychological arousal responses during sexual activity. Lower sexual desire among women reported prevalence of 40 percent, higher in women aged 65 and over.
Erectile disorder: Sexual dysfunction in which a man cannot attain or maintain an erection that is sufficient to allow them to initiate or maintain sexual activity. Prevalence increases in older samples of men, from 20 percent below age 30 to over 90 percent at age 70 and older. Increases in prevalence also linked to medical conditions, substance use.
Disorders Involving Orgasm
Female orgasmic disorder: Sexual dysfunction in which a woman experiences problems having an orgasm during sexual activity. Factors include stress, anxiety, depression, relationship satisfaction, age-related changes in the genital area, size and location of clitoris ,and lubrication issues. Older women are less likely to experience orgasmic difficulties than younger women.
Delayed ejaculation: Sexual dysfunction in which a man experiences problems having an orgasm during sexual activity (inhibited male orgasm).
Premature (early) ejaculation: Sexual dysfunction in which a man reaches orgasm with minimal sexual stimulation before, on, or shortly after penetration and before wishing to do so (within 1 minutes). Clinicians prefer to apply a psychiatric diagnosis only when the individual is distressed about the condition. Men who have sex exclusively with men or sex with both men and women have lower likelihood of premature ejaculation. Personality traits and being less willing to explore novel situations or tendency to avoid situations of potential risk can be related.
Disorders Involving Pain
Genito-pelvic pain/penetration disorder: Sexual dysfunction affecting both males and females that involves recurrent or persistent genital pain before, during, or after sexual intercourse. Cultural factors influence this as women may feel pressured by heteronormative social narratives. Research on transgender individuals indicates significant reduction in pelvic pain after hysterectomy, and greater reduction in sexual dysfunction after vaginoplasty or phalloplasty.
Theories and Treatments
Biological Perspective: There are higher rates of sexual disorders among men and women with a variety of health problems, suggesting an important role for biology. Climacteric is a gradual loss of reproductive potential that occurs in middle and later adulthood. Treatment includes hormonal replacement therapy, estrogen cream, and testosterone therapy.
Genito-pelvic pain/penetration disorder treated with physical therapy, neuromodulators implanted under the skin, Botox, and surgery. Erectile dysfunction treated with physical therapy, electrical stimulation, and biofeedback.
: medications for erectile disorder that increase blood flow to the genital area (e.g., , , and ).
Psychological Perspective: For women, preoccupation with overall body image is known to interfere with sexual functioning. For men, such cognitive disturbances can include self-image and concern about size of genitals, leading to anxiety in sexual situations. “Sexual self-schemas” such as feeling unloved, inadequate, and unworthy impact self- esteem and ability to maintain satisfactory sexual relationship. “Metacognitive” thinking—worry excessively about their thoughts creates difficulty in controlling stress.
Treatment includes cognitive behavioral therapy to help alleviate symptoms by restructuring cognitive disturbances. Sensate focus is used to treat sexual dysfunction in which the interaction is not intended to lead to orgasm but to experience pleasurable sensations during the phases prior to orgasm. Effortsshould not be limited based on age with older adults reporting relatively high prevalence of sexual difficulties lasting 3 months or longer.
Gender Dysphoria
Gender dysphoria is distress that may accompany the incongruence between a person’s experienced or expressed gender and that person’s birth-assigned sex. It is reserved for those who experience it and are unable to make changes to affirm their gender identity.
Birth-assigned sex refers to sex assigned to the individual at birth based on either genitalia and/or prenatal sex discernment.
Whereas past saw transgender people as having a “disorder,” new terminology focuses on psychological distress that can emerge from not being affirmed in one’s gender identity.
Transgender is the identity of a person whose assigned gender does not correspond with their gender identity. Unlike individuals with transvestic disorder, these people do not derive sexual gratification from cross-dressing. Not all transgender people see themselves in the binary categories, and might instead identify with several genders or no gender. The term non-binary corresponds to the notion that gender is seen through the lens of society as binary.
DSM-5-TR changed from pathologizing term of gender identity disorder to gender dysphoria. Most recent diagnostic category focuses specifically on psychological suffering associated with mismatch between birth-assigned sex and individual’s sense of own gender.
Transphobia is negative stereotyping and fear of transgender individuals. Another source of discrimination is lack of access to health care due to higher rates of unemployment and policies that prevent them from accessing gender-affirming care.
Theories and Treatment
New approaches are used that emphasize a more fluid view of gender than the binary male–female dichotomy.
Gender-affirming medical procedures are biological treatments including hormone replacement therapy and surgery for people with gender dysphoria and have well-established positive outcomes and have shown significant long- term satisfaction and reduction of gender dysphoria. Clinicians can provide support through psychotherapy as well as assisting clients in the decision to seek out gender-affirming medical procedures.
Affirmative psychotherapy is an approach treating transgender clients in which clinicians help their clients safely explore their gender identity, explore options for gender-affirming medical procedures, and connect with sources of social support.
Sexual disorders constitute three discrete sets of difficulties in aspects of sexual functioning and behavior. Clinicians are increasingly developing models that incorporate integrated treatment.
DSM-5-TR’s sweeping changes reflect expansion of the empirical approaches to sexual disorders and adoption of a broader, more inclusive, and socioculturally sensitive approach to their understanding and treatment.