Exercise: Normal vs.

Abnormal Sexual Activities

Rate the following on a 1 to 5 scale (strongly disapprove to
strongly approve):
Premarital sex when engaged
Premarital sex with casual acquaintance
One-night stands
Masturbation
Homosexuality
Extramarital affairs
Oral sex
Anal intercourse
Cross dressing to achieve sexual arousal
Pornography
Violent pornographic films
Discussion Points: What’s normal? Sources of views? How do our
discomfort talking about sex and sexual taboos affect the recognition and
treatment of sexual disorders?
SEXUAL & GENDER IDENTITY DISORDERS
Core Concept of Diagnostic Group
Difficulty in expression of normal sexuality, including:
Confusion about gender identity
Decreased sexual desire or arousal
Difficulty having or timing orgasm
Pain or discomfort during sex
The use of nonhuman objects for sexual arousal
Disturbing sexual acts & fantasies, e.g. sadism,
masochism, sexual activity with children or nonconsenting
adults
Sexual disturbance causes clinically significant distress
or impairment in social, occupational, or other
important areas of functioning
SEXUAL & GENDER IDENTITY DISORDERS
3 Large Categories of Disorders:
1) Sexual Dysfunctions – problems
with sexual desire, arousal, orgasm,
pain, or functioning
2) Paraphilias – disorders of the object
of sexual expression
3) Gender Identity Disorders –
disorders of sexual identity
 Sexual Disorders
Sexual Dysfunctions: problems may occur in any of
the phases of the Normal Sexual Response Cycle
(Master’s & Johnson)
1) Appetitive: sexual fantasies & desire for sexual activity
2) Excitement: sexual arousal and pleasure,
accompanied by physiological changes
3) Orgasm: sexual pleasure reaches a peak, followed by a
sudden release of tension, accompanied by rhythmic
contractions and pelvic thrusting
4) Resolution: sense of relaxation & well-being; male is
refractory to further erection & orgasm; females may
respond to stimulation with additional orgasms
Paraphilias: problem is defined by the nature of the
object or situation that is the focus of desire & arousal in
the 1st two phases of the sexual cycle
 Sexual Disorder Evaluation
Other psychiatric symptoms/disorders
General medical conditions
Substance use/abuse, including OTC & prescription medications
Main sexual complaint
Current sexual desire – decreased, absent, increased (hypoactive
sexual desire, sexual aversion disorder, hyperactive sexual desire)
Difficulty becoming aroused (sexual arousal disorder, erectile disorder)
Problems with orgasm (orgasmic disorders, premature ejaculation)
Pain associated with sex (dyspareunia, vaginismus)
Difficulty performing sexually with a mutually consenting person
Current and past sexual fantasies
Fetishes – use of objects for arousal
Urges/fantasies involving hurting or violating another’s rights
(exhibitionism, frotteurism, pedophilia, sadism, voyeurism) or being
made to suffer (masochism) during a sexual act
History of cross-dressing
Current preferences for sexual partner, e.g. age (pedophilia), sex
(homosexuality or bisexuality)
Gender identity – strong identification with opposite sex; persistent
discomfort with one’s own sex (gender identity disorder)
 Sexual Dysfunctions
Sexual Desire Disorders Orgasmic Disorders
Hypoactive Sexual Desire Female Orgasmic
Disorder Disorder
Sexual Aversion Disorder Male Orgasmic Disorder
Hypersexuality (Sexual Premature Ejaculation
Addiction) Other Disorders of
Sexual Arousal Disorders Sexual Dysfunction
Female Sexual Arousal Sexual Dysfunction due
Disorder to a General Medical
Male Erectile Disorder Condition
Sexual Pain Disorders Substance-Induced
Sexual Dysfunction
Dyspareunia
Sexual Dysfunction Not
Vaginismus
Otherwise Specified
 Sexual Desire Disorders
Too much or too little sexual desire
Mismatch in interest between 2 people in a relationship
– a relationship problem
HYPOACTIVE SEXUAL DESIRE DISORDER
Symptoms:
Deficient or absent sexual fantasies and desire for
sexual activity
Low libido – lack of interest in sex
Gender Factors: 22% of women & 5% of men;
prevalence increases with age for men and decreases
with age for women
Treatment:
Testosterone for men
Estrogen and/or Androgen for women
Couples Therapy
 Sexual Desire Disorders
SEXUAL AVERSION DISORDER
Symptoms:
Extreme aversion to and avoidance of all,
or almost all, genital sexual contact with
a sexual partner
Treatment:
Individual therapy to address underlying
issues, previous trauma, panic disorder
 Sexual Desire Disorders
HYPERSEXUALITY/SEXUAL ADDICTION (Not a DSM Dx)
Previously known as nymphomania (women) & satyriasis
(men)
Symptoms: excessive, compulsive sexual behavior,
characterized by feeling out of control
4 Stage Cycle:
1) increased craving for sex
2) ritualized search for sex
3) sexual behavior
4) period of guilt and despair
Causes:
Medical/organic: MS, epilepsy, strokes, tumors, brain
injury, dementia
Psychological: mania, psychosis, trauma, history of
sexual abuse or assault
Treatment: individual therapy; SSRI’s
 Sexual Arousal Disorders
FEMALE SEXUAL AROUSAL DISORDER
Symptoms
Inability to attain or maintain an adequate lubrication-
swelling response of sexual excitement until completion
of sexual activity
Failure in the early processes of arousal, such as vaginal
lubrication, engorgement of vaginal wall, clitoral
erection
Can make sex painful or unpleasant
Treatment:
Use of lubricants
Sex therapy (sensate focus, nondemand pleasuring,
nongenital pleasuring)
 Sexual Arousal Disorders
MALE ERECTILE DISORDER (Impotence)
Symptoms: Inability to attain or maintain an
adequate erection until completion of sexual
activity
Specifiers: Primary (life-long); Secondary
(after history of normal erections)
4 Basic Types:
No erection
Partial erection insufficient for sex
Full erection lost before sex is completed
Erection occurs sometimes, but not when
person wants it to
 Sexual Arousal Disorders
MALE ERECTILE DISORDER
Causes: smoking, alcohol, obesity, drugs, low levels of
testosterone, vascular disease, hypertension, diabetes,
aging, trauma, stress, performance anxiety, depression
Treatments:
Surgical: insertion of penile implants, penile artery
bypass
Mechanical devices: vacuum constriction draws
blood into penis
Medications: Viagra, Cialis, Levitra
Injections: injecting vaso-dilating drugs into the penis
Lifestyle changes: sex earlier in the day, losing
weight, quitting smoking, exercising
Relationship counseling
Prevalence: most common sexual problem for which
men seek help; increases with age
 Orgasmic Disorders
FEMALE ORGASMIC DISORDER
(Inhibited Female Orgasm)
Symptoms: Delayed or absent orgasms following
normal sexual excitement
Diagnosis: take age, sexual experience, and
adequacy of sexual stimulation into account
Prevalence: 10-15% never experience orgasms;
2/3rds don’t experience orgasms regularly
Causes: neurological damage, antihypertensive
drugs, antidepressants, tranquilizers, heart attacks,
relationship crisis
Treatment: directed program of self-stimulation &
increased communication between couple
 Orgasmic Disorders
MALE ORGASMIC DISORDER
(Inhibited Male Orgasm)
Symptoms: delayed or absent orgasms following
normal sexual excitement with adequate focus,
intensity, duration
Diagnosis: take age, sexual experience, and
adequacy of sexual stimulation into account
Causes: neurological damage, antihypertensive
drugs, antidepressants, tranquilizers, heart attacks,
relationship crises
Treatment: directed program of self-stimulation &
increased communication between couple
Prevalence: 8%
 Orgasmic Disorders
PREMATURE EJACULATION
• Symptoms: ejaculating with minimal sexual
stimulation before, upon, or shortly after
penetration and before one wishes to
• Prevalence: the most frequent sexual dysfunction;
21% of males in the U.S.
• Diagnosis: take age, duration of sexual
excitement, novelty of sexual partner or situation,
and frequency of sexual activity into account
• Causes: early learning; inexperience; performance
anxiety; prostatitis
• Treatment: sex therapy (stop-start procedure,
sensate focus); drugs
 Sexual Pain Disorders
DYSPAREUNIA
• Symptoms: painful sex; persistent genital pain before,
during or after sexual intercourse
• Causes: malformation of genitals; scars from childbirth or
surgery; vaginal infections; dryness; atrophy;
allergy/sensitivity to latex or spermicides
• Prevalence: 1-5% of men & 10-15% of women in clinics
VAGINISMUS
• Symptoms: vaginal spasms or contractions; recurrent or
persistent involuntary spasms of vaginal muscles that
interfere with sexual intercourse
• Causes: psychological (nonorganic)
• Prevalence: 5% of women in U.S.
• Treatment: use of larger & larger dilators; nongenital &
genital pleasuring
 Sexual Dysfunctions
• Sexual Dysfunction due to a General
Medical Condition, e.g. prostrate
surgery

• Substance-Induced Sexual Dysfunction,

e.g. alcohol, anxiolytics

• Sexual Dysfunction Not Otherwise

Specified
 Specifiers for Sexual Dysfunctions
Duration:
•Lifelong – present since onset of sexual functioning
•Acquired – develop after a period of normal functioning
Pervasiveness:
•Generalized – not limited to certain types of stimulation,
situations, or partners
•Situational – limited to certain types of stimulation, situations,
or partners
Etiology:
•Due to Psych Factors – psych factors play a major role in
onset, severity, exacerbation or maintenance of sexual
dysfunction; general medical conditions & substances play no
role in etiology
•Due to Combined Factors – both psych factors & a general
medical condition or substance use play a role in etiology
Sexual Dysfunctions: Diagnostic Considerations
Consider Normalcy
Is the dysfunction significant to warrant diagnosis?
Difficult to judge what’s normal/adequate sexual potency,
performance, and desire due to variability among
individuals, relationship match-ups, & cultural norms
Need to take into account age, level of experience,
cultural & religious mores, adequacy of sexual
stimulation, degree of interpersonal distress or difficulty
Be careful to follow judgment of patient and couple,
rather than imposing your own
Determine Etiology:
psychological factors (e.g. other psychiatric disorders)
general medical conditions (e.g. physical problems,
hormonal changes)
side effects of medication or substances
Sexual Dysfunctions: Contributing & Associated Factors
Gender – occur more often in women than men
Age – onset usually after the age 30, but may occur before;
increased incidence with old age; incidence decreases for
women and increases for men with age
Health problems – cardiovascular disease, high blood
pressure, diabetes, fatigue, overall poor health
Hormonal factors – estrogen deprivation, especially in
postmenopausal women, hormonal imbalances
Substance use – alcohol, medications
Emotional problems – depression, stress, anxiety, fear, anger,
guilt
Prior sexual experiences: sexual abuse, traumatic or
negative sexual experiences
Life stress: devoting excessive energy to other activities such
as work or travel
Relationship problems – lack of communication, lack of
affection, power struggles, conflict, lack of time together lack of
emotional attachment, difficulty attaining or maintaining intimate
relationships
Sexual Dysfunctions: Treatment Planning
Evaluate motivation to change sexual functioning
and to build a more satisfying sexual relationship.
Cognitive Behavioral Sex Therapy: teaching
couple about sex; homework exercises involving
giving each other pleasure, e.g. showering together,
massages, petting; permission to enjoy each other.
Psychodynamic Therapy: exploring sexual fears &
wishes; exploring effect of early sexual experiences;
addressing guilt
Relationship Counseling: addressing relationship
issues
Medications
 Paraphilias
Diagnostic Criteria:
6+-month history of recurrent, intense sexual
urges and sexually arousing fantasies involving:
nonhuman objects
the suffering or humiliation of either partner
sexual activity with a nonconsenting partner
Person has acted on these sexual urges, or the
sexual urges or fantasies cause marked distress
or interpersonal difficulty
Covers any unusual or problematic sexual desire
or behavior
 Paraphilias
EXHIBITIONISM (“Flashers”)
Symptoms/Characteristics:
recurrent, intense sexually arousing fantasies or
behaviors involving exposing one’s genitals to
unsuspecting strangers
aroused by rxn of shock, fear, amusement – see
these as a reciprocation of sexual interest
Prevalence: very common; accounts for over
1/3rd of all sex crime convictions in the US & other
countries
Gender Difference: more male exhibitionists
Diagnostic Considerations: distinguish between
intense sexual urges & socially sanctioned displays
 Paraphilias
FETISHISM
Symptoms:
recurrent, intense sexually arousing fantasies,
sexual urges, or behaviors involving the use of
inanimate objects, e.g. feet, buttocks, legs,
shoes, women’s lingerie, rubber, silk, leather
typically object must be involved in sexual act in
order for the participant to become aroused
Etiology: classical conditioning
 Paraphilias
FROTTEURISM (“Masher”)
Symptoms:
Recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors
involving touching and rubbing against a
nonconsenting person
Typically men who are sexually fixated on
physical contact with women without their
consent or knowledge
 Paraphilias
VOYEURISM (“Peeping Tom”)
Symptoms/Characteristics:
Recurrent, intense sexually arousing fantasies,
sexual urges, or behaviors, involving observing
an unsuspecting person who is naked, in the
process of disrobing, or engaged in sexual
activity
Men who are erotically focused on watching
women who are undressing, naked, or engaged
in sexual behavior
Prevalence: most common of all paraphilias
 Paraphilias
PEDOPHILIA:
Symptoms:
Recurrent, intense sexually arousing fantasies, sexual
urges, or behaviors involving sexual activity with
prepubescent children
Individual is at least 16 years old & is at least 5 years
older than the child
Sexual interest in prepubescent children exceeds
interest in physically mature adults
Specifiers:
if sexually attracted to males, females, or both
if limited to incest (intrafamilial vs. extrafamilial)
if exclusive (attracted only to children) or nonexclusive
 Paraphilias
PEDOPHILIA
Associated Features:
Overly touchy and affectionate with kids
Like to spend time alone with kids
Lack of intimate partners
Never been married
Poor relationship with one’s mother
Alcohol abuse
Low self-esteem
Repeated lying
Relatively low levels of intellectual function
History of child sexual abuse
 Paraphilias
PEDOPHILIA (CONTINUED)
Gender:
Vast majority are male & heterosexual –
heterosexuals outnumber homosexuals by 2 or 3
to 1
Course: begins at adolescence and persists over a
lifetime
Legal Issues:
Megan’s Laws – registration of sex offenders &
notification of public
Long prison sentences
Compulsory drug treatments
Most convictions are for nonpenetrative acts, e.g.
touching child’s buttocks or genitals
 Paraphilias
SEXUAL MASOCHISM
Symptoms:
Recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving the act of being humiliated, beaten, bound, or
otherwise made to suffer
Sexually fixated on receiving pain or humiliation or being bound
Submission is the key erotic element
SEXUAL SADISM
Symptoms:
Recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving acts in which the physical and/or psychological
suffering, including humiliation, of the victim is sexually exciting to the
person
Sexually fixated on inflicting pain or placing partner in a humiliating
position by means of bondage or physical abuse
Dominance is the key erotic element
Physical pain may involve: spanking, paddling, whipping, piercing,
cutting, burning, nipple clamping, cock and ball torture
 Paraphilias
TRANSVESTIC FETISHISM:
Symptoms:
Recurrent, intense sexually-arousing
fantasies, sexual urges, or behaviors
involving cross-dressing (wearing clothes
normally associated with individuals of the
opposite sex)
Usually applies to men who wear women’s
undergarments, dresses, etc.
Cross dressing for sexual arousal – male
wears female clothing and fantasizes that
he’s an alluring women
 Paraphilias

Bestiality: sexual contact between

humans and animals

Necrophilia: sexual fixation on

corpses; aroused by nonresistance of
dead partner
 Paraphilias: General Considerations
Diagnostic Considerations:
Paraphilias are exaggerations of common sexual desires &
behaviors
Sexual deviation or perversion: recurrent, intense, sexually
arousing fantasies, urges, or behaviors involving nonhuman
objects, suffering or humiliation of oneself or one’s partner
Can person only achieve arousal through paraphiliac
fantasies/stimuli? Can he/she function sexually in other situations?
Gender Differences: occurs almost exclusively in males
(except for sexual masochism)
Onset: tends to appear first in adolescence
Legal Issues:
Paraphiliac behaviors involving a nonconsenting individual or child
 arrest, incarceration
Being diagnosed with a paraphilia doesn’t absolve individual of
criminal responsibility for behavior
 Paraphilias: General Considerations
Associated Features:
Lack of social skills
Sense of inadequacy
Depression
Rage against women
History of sexual exploitation or abuse as children
Common to believe their behaviors are sexually
exciting/beneficial to their targets
Causes: exact causes remain unknown
Inherited
Conditioned/learned
Courtship disorder
Blockage of normal avenues of sexual expression
Victim-perpetrator cycle
Organic disorders – abnormal hormone levels, neurological
disease, chromosomal abnormalities, seizure disorders, dyslexia,
mental retardation
 Paraphilias: Treatment Planning
Variety of treatments:
Cognitive – correcting cognitive distortions, relapse
prevention
Behavioral – attempts to reverse pathological
learning by aversion, covert sensitization, orgasmic
reconditioning, positive and negative reinforcement,
social skills training
Psychodynamic
Hormones/Medication – Depo-Provera, Lupron,
androgen receptor antagonists, SSRI’s
Relationship work
Surgical – castration – removal of testicles to remove
main source of androgens
Optimal treatment and outcome are not well established.
Wide consensus: more severe cases/forms are persistent
& resistant to treatment
Importance of clinician’s managing their own feelings, e.g.
disgust, disapproval
 Gender Identity Disorders (Transsexualism)
Gender Identity Disorder in Children
Strong, persistent cross-gender identification,
manifested by at least 4 of the following:
1. repeated, stated desire to be, or insistence that
one is, the other sex
2. preference for cross-dressing; insistence on
wearing clothing stereotypical for other sex
3. Strong persistent preferences for cross-sex roles
or persistent fantasies of being the other sex
4. Intense desire to participate in stereotypical
games & pastimes of other sex
5. Strong preference for playmates of other sex
 Gender Identity Disorders
Gender Identity Disorder in Children (cont’d)
Persistent discomfort with one’s own sex or a sense of
inappropriateness in the gender role of that sex,
manifested by any of the following:
1. In boys, asserting that one’s penis and testes are
disgusting or will disappear or that it would be better
not to have a penis.
2. In boys, an aversion to rough-and-tumble play and a
rejection of stereotypically male toys, games, activities.
3. In girls, refusing to urinate in a sitting position.
4. In girls, asserting that one doesn’t want to grow breasts
or menstruate or that one will grow a penis.
5. In girls, a marked aversion to female clothing.
 Gender Identity Disorders
GID in Adolescents or Adults
Strong and persistent cross-gender
identification, manifested by sx such as:
• a stated desire to be the other sex
• frequent passing as the other sex
• a desire to live or be treated as other sex
• conviction that one has the typical feelings or
reactions of the other sex
 Gender Identity Disorders
GID in Adolescents or Adults (cont’d)
Persistent discomfort with one’s own sex or a
sense of inappropriateness in the gender role
of that sex, manifested by sx such as:
• preoccupation with getting rid of one’s primary
and secondary sex characteristics
• belief one was born the wrong sex
Specify if sexually attracted to males,
females, both, or neither.
 Gender Identity Disorder
Different than transvestic fetishism,
hermaphrodism, homosexuality
Prevalence: relatively rare; 1 in 30,000 men
& 1 in 100,000 women seek sex-reassignment
surgery
Gender differences: over 3x more men
seek sex-reassignment surgery
Causes: unknown, but biological
contributions, such as prenatal hormonal
exposure, have been emphasized
Course: chronic
 Gender Identity Disorders
Treatment Planning:
Alter identity to fit biological sex
Alter one’s body to align with one’s gender
identification
Sex reassignment surgery involves:
1. Psychological and physical evaluation
2. Real life experience living as opposite sex for 1-2
years
3. Hormone treatments
4. Surgery to reconstruct genitals
5. Follow-up evaluation