Chapter_12__Slides

Chapter 10: Sexual Dysfunctions, Paraphilias, and Gender Dysphoria

Three DSM-5 Categories

• Sexual Dysfunctions

• Paraphilic Disorders

• Gender Dysphoria

Sexual Dysfunctions

• Definition: Disorders that disrupt the sexual response cycle or cause pain during sexual activity.

• Sexual Response Cycle:

  • Desire

  • Excitement/Arousal

  • Orgasm

  • Resolution

Sexual Response Cycle by Gender

• The response cycle varies across genders, highlighting different perceptions and experiences of sexual function.

Types of Sexual Dysfunctions

Low Sexual Desire

1. Male Hypoactive Sexual Desire Disorder

2. Female Sexual Interest/Arousal Disorder

   • Symptoms: Lack of interest in sexual activity/fantasy

   • Contributing Factors: Personal, psychological, or relational issues.

Sexual Arousal Disorders

1. Female Sexual Interest/Arousal Disorder

   • Symptoms: Insufficient engorgement/lubrication.

   • Treatment: Couple's therapy focused on communication, Sensate Focus techniques.

2. Erectile Disorder (ED)

   • Definition: Inability to achieve or maintain an erection.

   • Treatment: Medications, Sensate Focus techniques, plus Paradoxical Instruction.

Orgasmic Disorders

1. Female Orgasmic Disorder

   • Definition: Difficulty in reaching orgasm.

   • Treatment: Education about female sexuality, self-stimulation instructions.

2. Delayed Ejaculation

   • Symptoms: Men experiencing difficulty reaching orgasm.

   • Treatment: Similar to ED treatments and female orgasmic disorder; may incorporate cues from masturbation.

3. Premature Ejaculation

   • Definition: Orgasm occurs before, on, or shortly after penetration.

   • Treatment Options: Special condoms, squeeze technique, start/stop technique.

Pain Disorders

• Genito-Pelvic Pain/Penetration Disorder

  • Female-specific condition characterized by:

    • Difficulty with penetration.

    • Tensing of pelvic muscles.

    • Anxiety about pain.

    • Marked pain during penetration.

  • Associated Conditions: Injuries, medical conditions, trauma.

  • Treatment: Physical therapy, learning control of vaginal muscles, gradual exposure to penetration.

Diagnosing Sexual Dysfunction

• Lifelong Dysfunction: Present since early sexual experiences.

• Acquired Dysfunction: Develops post-normal functioning period.

• Generalized Dysfunction: Present in all sexual situations.

• Situational Dysfunction: Occurs in certain situations or with specific partners.

Risk for Sexual Dysfunction by Gender

• Differences in prevalence and risk factors for sexual dysfunction among different genders.

Defining Normal Sexuality

• Implicit definitions of normal sexuality vary widely.

Paraphilias

• Defined as patterns of sexuality that deviate from cultural norms, causing distress, impairment, or affecting others.

Types of Paraphilias

1. Fetishistic Disorder: Reliance on inanimate objects or body parts for sexual gratification.

2. Transvestic Disorder: Sexual gratification through dressing as another gender.

3. Exhibitionistic Disorder: Sexual gratification through display of genitals to unwilling observers.

4. Voyeuristic Disorder: Sexual gratification through observing others’ sexual activities or anatomy.

Paraphilic Disorders

1. Sexual Sadism Disorder: Sexual gratification through inflicting pain/humiliation.

2. Sexual Masochism Disorder: Sexual gratification through self-inflicted pain/humiliation.

Normal Sexual Fantasies (Joyal, Cossette & Lapierre, 2014)

• Study on Canadian adults found common fantasies include:

  • Being dominated, tied up, or performing sexual acts in public (exhibitionistic).

  • Fantasies vary by gender, with men particularly engaging in sadistic or exhibitionistic fantasies.

Additional Paraphilias

1. Frotteuristic Disorder: Sexual gratification through rubbing against a non-consenting person.

2. Pedophilic Disorder: Sexual contact with prepubescent children (age separation of 5 years, perpetrator must be >16).

3. Unspecified Paraphilias: Include a wide range of unusual interests (e.g., necrophilia, enema, etc.).

Treatment for Paraphilias

• Behavioral Treatments:

  • Stimulus Satiation: Exposure to paraphilic stimuli post-orgasm.

  • Orgasmic Reconditioning: Shift to normative fantasies right before orgasm.

  • Covert Sensitization: Imagine worst-case scenarios during arousal.

• Medications: To reduce androgen activity (e.g., Depo Provera).

Gender Dysphoria

• Definition: Marked incongruence between experienced/expressed gender and assigned gender.

  • Criteria: Substantial distress, desire to live as experienced gender.

  • Categories: Gender Dysphoria in Children; Adolescents & Adults.

  • Prevalence: Low in adults (<0.1%), more prevalent in assigned males than females.

Gender Affirmative Treatment

• Treatment aligning body with gender identity.

  • Options: Hormones, surgeries, electrolysis, etc.

• Requirements for Gender Affirming Surgery:

  • Detailed mental health evaluation, hormonal therapy for 1 year, living full-time in experienced gender for 1 year.

Outcomes of Treatment

• 80% improvement in gender dysphoria with biological treatments.

• 70% satisfaction with gender-affirming surgery, with satisfaction increasing over time.

• Psychotherapy alone ineffective in reducing gender dysphoria.

• Conversion Therapy: Denounced as unethical by APA.

Causes of Gender Variation

• Neuroscience Findings:

  • Monozygotic twins show concordance for gender dysphoria.

  • Central nervous system differences in blood flow and response among genders.

  • Anatomical differences in brain structures controlling sexuality.

Causes of Gender Dysphoria

• May exist due to biological disorders in sexual development (e.g., androgen insensitivity).

Ethical Implications

• Inclusion of gender dysphoria in DSM-5 may stigmatize and pathologize non-binary identities.

• Treatment and insurance coverage often contingent on formal diagnosis.

• Mental health issues among LGBT populations fluctuate with changes in societal policies.

Documentary

• Gender Dysphoria in Children & Adolescents: Focus on experiences of transgender youth.