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CH-10-Sexual Dysfunctions, Paraphilic Disorders, & Gender Dysphoria – Comprehensive Study Notes

What is Normal Sexuality?

  • Sexuality = complex mix of biological drive, personal meaning, social learning, cultural scripts.
  • DSM-5 considers sexual experience DISORDERED only when there is:
    • Clinically significant distress/impairment in the individual, OR
    • Risk of harm or actual harm to non-consenting others.
  • Two broad clinical phenomena involving sexual behaviour
    • Sexual Dysfunctions – difficulty engaging in or enjoying consensual sexual activity.
    • Paraphilic Disorders – persistent sexual arousal to inappropriate objects/individuals.
  • Gender Dysphoria is no longer grouped with “sexual disorders”; core issue is incongruence between natal sex and experienced gender, not sexual activity per se.

Survey data & prevalence (CDC National Survey of Family Growth, Mosher et al 2005; Chandra et al 2011)

  • Sample sizes n \approx 12{,}500 (2005) and n>13{,}000 (2006-2008).
  • 81.3 % of men & 80.1 % of women (15-44 yrs) had experienced vaginal intercourse.
  • Oral sex (opposite-sex): 89 % men, 90 % women; Anal sex: 35.8 % men, 30.7 % women.
  • Lifetime partners ≥ 15 → 21.4 % men vs 8.3 % women.
  • Past-12-month partners ≥ 4 → 6 % men vs 2.9 % women.
  • Same-sex behaviour ever: 6.5 % men; attraction only-to-same-sex = 2.2 % men, ~2 % women.
  • Emerging identities: asexual, pansexual etc ~1 % when option given.
  • Cross-national replication (UK, France): similar patterns; >70 % have ≤ 1 partner/yr.

Sexuality in Later Life (Lindau et al 2007)

  • 57-64 yrs: 83.7 % men, 61.6 % women sexually active; 67.5 % men report activity ≥ 2-3×/month.
  • 75-85 yrs: 38.5 % men, 16.7 % women sexually active.
  • Predictors of well-being: good physical/mental health, relationship quality, partner availability.

Gender Differences in Sexuality

  • Robust findings (Oliver & Hyde 1993; Petersen & Hyde 2010):
    • Men masturbate more (Australia 2014: 72 % men vs 42 % women, past-year).
    • Men endorse more permissive attitudes toward casual/pre-marital sex, porn use.
    • Women emphasise commitment; men’s sexual self-schema includes power, aggression.
    • Women’s sexual beliefs more “plastic” – orientation & frequency fluctuate (Diamond 2007).
    • Arousal specificity: heterosexual men respond to female stimuli; women (hetero or lesbian) respond to both male & female stimuli (Chivers et al 2004).
  • Hook-up culture: 40 % of first-year college women engage at least once; still <½ frequency of romantic-relationship sex.
  • Alcohol amplifies casual sex participation, esp. in women (Owen & Fincham 2011).

Cultural Differences & Anthropological Examples

  • Sambia (Papua New Guinea): ritualised adolescent male homosexual acts believed necessary for growth; heterosexual marriage expected later.
  • Munda (India): mixed-sex dormitories encourage heterosexual petting.
  • Sweden vs USA (Schwartz 1993): contraception at first sex 74 % vs 57 %; perceived acceptable age for premarital sex lower & equal across genders in Sweden.
  • Chinese urban adults (Garcia et al 2014): determinants of satisfaction similar to West.

Development of Sexual Orientation

  • Twin studies – concordance for male homosexuality ≈ 50 % MZ vs 16-22 % DZ.
  • Heritability estimates: men 34-39 %, women 18-19 % (Långström et al 2010).
  • Prenatal hormone theories: CAH females more masculine behaviour; mixed evidence on 2D:4D finger ratios; fraternal birth-order effect – each older brother ↑ odds of male homosexuality by ≈ 33 % (Blanchard 2008).
  • Epigenetic hypotheses: sex-specific epi-marks may canalise sexual orientation (Balter 2015).
  • Sexual fluidity greater in women – > 2/3 changed identity label over 10 yrs (Diamond 2012).

Sexual Dysfunctions (DSM-5)

Desire Phase

  • Male Hypoactive Sexual Desire Disorder – deficient sexual thoughts/fantasies ≥ 6 mths + distress.
  • Female Sexual Interest/Arousal Disorder – ≥ 3 of 6 desire/arousal deficits.

Arousal Phase

  • Erectile Disorder – difficulty obtaining/maintaining erection ≈ 5 % men 18-59; prevalence ↑ to 60 % by 60+.
  • Female SI/AD – lubrication/engorgement problems; prevalence 7-14 %.

Orgasm Phase

  • Female Orgasmic Disorder – delay/absence or reduced intensity; 25 % women report difficulty, but only ‘almost never/never’ + distress qualifies.
  • Delayed Ejaculation – 8 % men.
  • Premature (Early) Ejaculation – ejaculation ≤ 1 min after penetration; lifetime prevalence 21 % men.

Pain/ Penetration

  • Genito-Pelvic Pain/Penetration Disorder – pain, fear, tensing; includes vaginismus (outer-third muscular spasm). Recurring pain reported by 7-15 % women.

Specifiers

  • Lifelong vs Acquired; Generalised vs Situational; Severity.

Assessing Sexual Behavior

  • Multi-modal evaluation
    • Structured interview (comfort, vernacular).
    • Medical exam – vascular, neuro, hormonal, medication side-effects, e.g. SSRIs, beta-blockers.
    • Psychophysiological tests – penile strain-gauge, vaginal photoplethysmograph during erotic stimuli.

Causes of Sexual Dysfunction

  • Biological: vascular disease, diabetes (28 % complete ED), neurological illness, chronic alcohol (75 % men with alcoholism ED), nicotine & cocaine ↓ arousal, SSRIs cause 50 %+ sexual side-effects.
  • Psychological: performance anxiety model (Barlow 1986)
    • Functional loop – focus on erotic cues → ↑ arousal.
    • Dysfunctional loop – expectation of failure, spectatoring, distraction.
  • Social/Cultural: erotophobia, early abuse, relationship discord, restrictive scripts.

Treatments for Sexual Dysfunction

  • Psychosocial (Masters & Johnson; Kaplan; Wincze & Barlow)
    • Education + myth-debunking.
    • Sensate Focus & Nondemand Pleasuring – 2-phase nongenital then genital with ban on orgasm initially.
    • Squeeze technique for premature ejaculation (Semans 1956) 60-90 % short-term success.
    • Masturbatory training & vibrator for female orgasmic disorder (70-90 % success).
    • Dilators + relaxation for vaginismus (80-100 % success).
  • Medical
    • PDE-5 inhibitors – Sildenafil, Tadalafil, Vardenafil; ~50-80 % obtain functional erection; headaches 30 %.
    • Intra-penile vasoactive agents (papaverine, prostaglandin); MUSE urethral pellets.
    • Vacuum erection devices; penile prostheses.
    • Hormonal options: testosterone for hypoactive desire; flibanserin (“pink Viagra”) modest benefit in women – controversial.

Paraphilic Disorders (DSM-5)

  • Criteria: (A) pervasive, intense sexual interests beyond phenotypically normal, consenting adults, ≥ 6 mths, and (B) distress/impairment or acted on with non-consenting person.

Disorders & Core Features

  • Frotteuristic – touching/rubbing non-consenting persons (crowded transport).
  • Fetishistic – inanimate objects or non-genital body parts; common: lingerie, shoes.
  • Voyeuristic – spying on unsuspecting naked/sexual activity; must be ≥ 18 yrs.
  • Exhibitionistic – exposing genitals to strangers; thrill of shock, risk.
  • Transvestic – arousal from cross-dressing; specifiers: with fetishism; with autogynephilia.
  • Sexual Sadism – arousal from suffering of another; includes sadistic rape subtype.
  • Sexual Masochism – arousal from being humiliated, beaten; hypoxiphilia danger.
  • Pedophilic Disorder – attraction to prepubescent child (≤ 13 yrs), perpetrator ≥ 16 yrs & ≥ 5 yrs older; specifiers: exclusive/non-exclusive, sex of children, incest.
  • Female paraphilic disorders rare (≈ 5-10 % sexual offenders); patterns include pedophilia, exhibitionism, sadomasochism.

Etiology Model (Marshall & Barbaree; Ward & Beech)

  • Early inappropriate sexual associations + conditioning → deviant fantasy reinforced by masturbation.
  • Inadequate development of adult arousal patterns & social skills.
  • Strong sex drive + weak inhibition (possible low serotonergic BIS).

Assessment

  • Detailed interview; penile plethysmography to various stimuli; self-report scales.

Treatment

  • Psychological
    • Covert sensitisation – pair deviant fantasy with aversive imagery.
    • Orgasmic reconditioning – shift fantasy content during masturbation.
    • Relapse Prevention – identify high-risk situations, coping.
    • CBT packages for offenders: mixed outcomes; 10-20 % reduction in sexual recidivism; better in outpatient than prison; motivation & empathy modules.
  • Medical (anti-androgen)
    • Cyproterone acetate; medroxyprogesterone; GnRH analogues (triptorelin) – suppress testosterone, reduce fantasy; compliance crucial.

Gender Dysphoria

  • Key feature: marked incongruence between experienced gender & assigned sex ≥ 6 mths with distress.
  • Prevalence: natal males 0.005-0.014 %; natal females 0.002-0.003 %; M : F ≈ 3 : 1.
  • Specifier “post-transition” when living full-time in desired gender.

Development & Etiology

  • Gender identity solidifies by age 1.5!–!3 yrs.
  • Twin heritability ≈ 62 % (Coolidge 2002); structural brain differences (BSTc) resemble experienced gender.
  • Congenital adrenal hyperplasia females more masculine behaviour but usually female identity.
  • Psychosocial factors: gender-nonconforming play, cross-sex peer preference; majority of such children do not persist into adulthood; outcome often homosexual orientation.

Assessment & Treatment

  • Multidisciplinary gender clinics.
  • Adults – Stepwise:
    1. Comprehensive evaluation & psychoeducation.
    2. Real-life experience living in desired gender 12-24 months.
    3. Hormone therapy (oestrogen + anti-androgen for transwomen; testosterone for transmen).
    4. Sex reassignment surgery (SRS) – vaginoplasty/penectomy in transwomen; mastectomy & phalloplasty/metoidioplasty in transmen; satisfaction 75-100 %; regret 1-7 %.
  • Children/Adolescents
    • Psycho-education & family support; watchful waiting vs affirmative approach; CBT for distress.
    • Puberty blockers (GnRH analogues) at Tanner stage 2 to delay irreversible changes; later cross-sex hormones if persisting.
  • Disorders of Sex Development – move away from early irreversible surgery; individualised plan.

Ethical & Societal Implications

  • Balancing individual autonomy with societal norms; ensuring consent & preventing harm in paraphilic interests.
  • Health-care access disparities: older adults’ sexuality under-addressed; transgender care limited by legislation & availability.
  • Cultural competence crucial – wide normative variation across cultures & within LGBTQIA+ identities.