Module 12

Sexual Deviations

Overview of Topics

  • Gender Dysphoria

    • Diagnostic Criteria

    • Treatment

    • APA Guidelines

  • Paraphilias

Gender Dysphoria

Definition

  • Gender dysphoria is characterized by a marked difference between an individual's experienced or expressed gender and their assigned sex at birth, leading to significant distress or impairment.

Diagnostic Criteria

  • For a diagnosis, an individual must exhibit at least two of the following for a minimum duration of 6 months:

    • A marked difference between experienced (expressed) gender and one’s own sex characteristics

    • A strong desire to be rid of one’s primary and/or secondary sex characteristics

    • A strong desire to possess the sex characteristics of the other gender

    • A strong desire to be a different gender

    • A strong desire to be treated as a different gender

    • A strong conviction that one has the typical feelings and reactions of a different gender

  • The condition is linked to significant distress affecting social, occupational, or important areas of functioning.

Reason for Diagnosis Inclusion in DSM-5

  • Arguments for Removal:

    1. Not a mental disorder; it is a normal variant of gender identity.

    2. Its inclusion contributes to stigma against individuals with gender incongruence.

    3. There isn't anything inherently wrong with being gender incongruent.

  • Arguments for Retention:

    1. In order to ensure access to care such as insurance coverage and treatments.

    2. Reconceptualization focuses on the distress and impairment associated with gender incongruence.

Case Study: Childhood-Onset Gender Dysphoria

  • Example of Austin:

    • Insisted he was a girl while showing behaviors such as trying on women's clothes and wanting to be around girls.

    • Experienced teasing and distress from peers and expressed a wish to “cut off” his penis, indicating a significant level of distress associated with his gender identity.

Epidemiology

  • Prevalence:

    • In the US (2016): approximately 0.5%

    • Worldwide: ranges from 0.1% to 0.7%

  • Increased prevalence of reported cases, highlighting rising help-seeking behavior.

  • Average Age of Onset:

    • Reported to be around 8.3 years.

Etiology of Gender Dysphoria

  • Likely results from an interaction of several factors:

    • Biological Factors:

    • Genetics and neurohormonal influences.

    • Psychological/Social Factors:

    • Caution urged regarding how social and environmental influences may play a role.

Treatment Approaches

  • Goals:

    • Assist individuals in discovering and expressing their true gender identity.

    • Implement social and legal transitions if desired.

    • Involve family therapy where necessary.

    • Ensure access to medical services and interventions ranging from less invasive to more invasive treatments.

APA Guidelines

  • Foundational Knowledge and Awareness:

    • Acknowledge that gender is nonbinary and recognize that gender identity might not align with biological sex.

    • Understand that gender identity and sexual orientation are distinct yet interconnected.

    • Promote awareness of intersectional identities and the influence of one's attitudes on quality of care.

  • Stigma, Discrimination, and Barriers to Care:

    • Recognize how stigma and violence can adversely affect health and the need to combat institutional barriers to create affirming environments.

    • Focus on promoting social change to reduce the negative impacts of discrimination.

  • Assessment, Therapy, and Intervention:

    • Advocate for an interdisciplinary approach in providing care.

Paraphilic Disorders

Definition

  • Paraphilic disorders involve sexual arousal from atypical objects, situations, or individuals, and may cause significant distress, impairment, or harm to the individual or others.

Characteristics

  • Types of Paraphilic Disorders:

    • Disorders typically involve misplaced sexual attraction toward inappropriate people or objects and may frequently co-occur with anxiety, mood, or substance use disorders.

Manifestations

  • Paraphilia can appear in various forms including fantasies, urges, and behaviors.

  • Distinction between coercive and non-coercive paraphilias:

    • Considered disordered only if experienced clinically significant distress/impairment, or acted upon urges with nonconsenting individuals.

DSM-5 Paraphilic Disorders

  • Categories of Disorders Include:

    • Fetishistic Disorder:

    • Sexual attraction to nonhuman objects (e.g., rubber, specific clothing items).

    • Transvestic Disorder:

    • Sexual arousal tied to cross-dressing; considered disordered if it causes significant distress or impairment.

    • Exhibitionist Disorder:

    • Engaging in exposing genitals to non-consenting strangers, which provides a thrill.

    • Voyeuristic Disorder:

    • Observing unsuspecting individuals engaged in sexual activity.

    • Frotteuristic Disorder:

    • Achieving sexual gratification from rubbing against unwilling individuals, often in crowded situations.

    • Sexual Sadism:

    • Inflicting pain or humiliation for sexual gratification.

    • Sexual Masochism:

    • Receiving pain or humiliation for sexual satisfaction.

    • Pedophilic Disorder:

    • Sexual attraction to prepubescent children, with most diagnosed individuals being male.

Treatment of Paraphilic Disorders

  • Treatments often include:

    • Incarceration and court-ordered treatment.

    • Cognitive Behavioral Therapy (CBT):

    • Methods include covert sensitization, orgasmic reconditioning, and addressing distorted cognitive patterns, often integrated with social skills training.

    • Biological Treatments:

    • Prior use of castration and hormonal agents that reduce testosterone levels, such as cyproterone acetate, medroxyprogesterone, or triptorelin.

    • Challenges in Treatment:

    • Mixed efficacy; factors like denial of problems, victim-blaming attitudes, lack of motivation, and dropout rates can hinder effective treatment.

Sexuality and Sexual Dysfunctions

Notions of "Normal" Sexual Behavior

  • The concept of normal sexual behavior is influenced by normative statistics and cultural considerations, with gender differences also playing a role.

Statistics on Sexual Behavior

  • Lifetime Partners:

    • Males: 21.4% had 15 or more partners.

    • Females: 8.3% with similar history.

  • Recent Partners (Past Year):

    • Males: 6% had 4 or more partners.

    • Females: 2.9% had the same.

  • Same-Sex Attraction:

    • Males: 10%.

    • Females: 9%.

Lifespan and Sexual Activity

  • Sexual activity can extend beyond age 80:

    • Ages 75 to 85: 38.5% of males and 16.7% of females are sexually active.

    • Declines in sexual activity are often due to physical health changes.

Sexual Dysfunctions Description

  • Involves issues related to desire, arousal, and/or orgasm that leads to considerable distress or impairment lasting over 6 months.

Prevalence of Sexual Dysfunctions

  • Extremely common, but not all cases lead to distress:

    • A study found approximately 40% of men experienced erectile or ejaculation issues; about 63% of women struggled with arousal or orgasm issues.

Classification of Sexual Dysfunctions

  • Types:

    • Lifelong vs. acquired dysfunctions.

    • Generalized vs. situational.

    • Psychological causes alone versus those combined with medical conditions.

Specific Dysfunctions

  • Male Hypoactive Sexual Desire Disorder:

    • Characterized by little to no interest in sexual activity, with prevalence at about 5% of men.

  • Erectile Disorder:

    • Difficulty in achieving or maintaining an erection, particularly prevalent among older males, affecting 60% of men over 60 years.

  • Female Sexual Interest/Arousal Disorder:

    • Significantly reduced interest/arousal, manifesting as fewer sexual thoughts and reduced pleasure during encounters.

  • Female Orgasmic Disorder:

    • Involves marked delays or absence in achieving orgasm, impacting significant numbers of women (1 in 4).

Conclusion

  • Understanding sexual deviations, including gender dysphoria and paraphilic disorders, requires sensitivity to their complexities. Ethical, philosophical, and cultural implications play a critical role in diagnosis and treatment approaches.

  • As professionals work within these fields, they need to navigate both the medical and psycho-social dimensions of sexual health.