Sexual Dysfunction and Desire Disorders

• Sexual dysfunctions involve problems with the human sexual response cycle or pain during intercourse.

Male Hypoactive Sexual Desire Disorder (DSM-5)

• Persistent or recurrent deficiency or absence of sexual/erotic thoughts, fantasies, and desire for sexual activity.
• Clinicians determine the level of deficiency based on factors like age and socio-cultural context.
• Symptoms must persist for at least 6 months.
• The symptoms must cause clinically significant distress.
• The dysfunction is not better explained by a nonsexual mental disorder, severe relationship distress, other stressors, or attributable to medication or another medical condition.
• Specify if it is lifelong or acquired, generalized or situational, and mild, moderate, or severe.

Female Sexual Interest/Arousal Disorder (DSM-5)

• Lack of, or significantly reduced, sexual interest/arousal, indicated by at least three of the following:
  • Absent/reduced interest in sexual activity.
  • Absent/reduced sexual/erotic thoughts or fantasies.
  • No/reduced initiation of sexual activity.
  • Typically unreceptive to a partner's attempts to initiate.
  • Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all sexual encounters.
  • Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues.
  • Absent/reduced genital or nongenital sensations during sexual activity in almost all or all sexual encounters.
• Symptoms must persist for at least 6 months
• The symptoms must cause clinically significant distress
• The dysfunction isn't better explained by a nonsexual mental disorder, relationship distress, other stressors, or a medical condition
• Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe

Erectile Disorder (DSM-5)

• At least one of the following must be experienced on almost all occasions of sexual activity:
  • Marked difficulty in obtaining an erection during sexual activity.
  • Marked difficulty in maintaining an erection until the completion of sexual activity.
  • Marked decrease in erectile rigidity.
• Symptoms must persist for a minimum duration of approximately 6 months.
• The symptoms must cause clinically significant distress to the individual.
• The sexual dysfunction is not better explained by a nonsexual mental disorder, severe relationship distress, significant stressors or is not attributable to the effects of a substance/medication or another medical condition.
• Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

Female Orgasmic Disorder (DSM-5)

• Includes the presence of either:
  • Marked delay in, marked infrequency of, or absence of orgasm,
  • Markedly reduced intensity of orgasmic sensations.
• Must be experienced on almost all or all occasions of sexual activity.
• Symptoms must have persisted for a minimum duration of approximately 6 months.
• The symptoms must cause clinically significant distress to the individual.
• The sexual dysfunction is not better explained by a nonsexual mental disorder, severe relationship distress, or attributable to medication or another medical condition.
• Specify if lifelong or acquired, generalized/situational, and/or mild, moderate, or severe. Specify if never experienced orgasm.

Delayed Ejaculation (DSM-5)

• Either of the following symptoms must be experienced on almost all or all occasions of partnered sexual activity, without the individual desiring delay:
  • Marked delay in ejaculation.
  • Marked infrequency or absence of ejaculation.
• Symptoms must last a minimum of 6 months.
• The symptoms must cause clinically significant distress to the individual.
• The sexual dysfunction is not better explained by a nonsexual mental disorder, severe relationship distress, or attributable to medication or another medical condition.
• Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

Premature (Early) Ejaculation (DSM-5)

• A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it.
• Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities.
• Persisted for at least 6 months and must be experienced on almost all or all occasions of sexual activity.
• The symptoms must cause clinically significant distress to the individual.
• Not better explained by a nonsexual mental disorder, severe relationship distress, or attributable to medication or another medical condition.
• Specify if lifelong or acquired, generalized or situational, and/or mild, moderate, or severe.

Genito-Pelvic Pain/Penetration Disorder (DSM-5)

• Persistent or recurrent difficulties with one (or more) of the following:
  • Vaginal penetration during intercourse.
  • Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
  • Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration.
  • Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
• Symptoms must have persisted for a minimum duration of approximately 6 months.
• The symptoms must cause clinically significant distress to the individual.
• The sexual dysfunction is not better explained by a nonsexual mental disorder, or a as a consequence of severe relationship distress, or other significant stressors and is not attributable to the effects of a substance/medication, or another medical condition.
• Specify if generalized or situational.

Epidemiology of Sexual Dysfunctions

• Sexual dysfunctions are common.
• They increase with age.
• They are often co-morbid with one another.
• They are often co-morbid with anxiety and depression.
• May be linked to medical, substance, and cultural factors.

Causes of Sexual Dysfunctions

• Causes include demands or expectations for sexual performance.
• Focus on consequences of inability to perform
• Increased physical arousal
• Intense focus on consequences of inability to perform
• Erectile dysfunction and avoidance of sex

Stigma Associated with Sexual Dysfunctions

• Stigma associated with sexual dysfunctions can be quite powerful.
  • For men, this includes “impotence” or erectile dysfunction.
  • For women, this includes recurrent painful intercourse or infertility.

Focus on College Students: Sexual Dysfunctions

• Sexual dysfunctions often increase in prevalence with age, especially for men; many college students may not think much about these problems.
• If a young adult does experience a sexual problem, substantial stigma may therefore apply.
• Self-stigma for a sexual problem was significantly related to less likelihood for seeking professional treatment.
  • Especially for men and for religious participants.
• Males were more likely to seek help from a family physician.
• Females were more likely to seek help from a gynecologist or urologist (Bergvall & Himelein, 2014).
• Sexual dysfunctions in college students often relate to experiences of sexual victimization.
• College women who had experienced sexual coercion or rape reported more sexual dysfunctions related to desire, arousal, and pain compared with nonvictims (Turchik & Hassija, 2014).
• College males who had been sexually victimized also report sexual functioning difficulties (Turchik, 2012).
• Male survivors of sexual assault are especially unlikely to disclose the event; they may be less likely to seek help for subsequent sexual dysfunction (Allen, Ridgeway, & Swan, 2015).

Assessment of Sexual Dysfunctions

• The Female Sexual Function Index includes the question, "Over the past 4 weeks, how often did you feel sexual desire or interest?”:
  • 5 = Almost always or always
  • 4 = Most times (more than half the time)
  • 3 = Sometimes (about half the time)
  • 2 = A few times (less than half the time)
  • 1 = Almost never or never

Biological Treatment of Sexual Dysfunctions

• Penile implants help the male organ become rigid for penetration during sex.

Psychological Treatments of Sexual Dysfunctions

• Sensate focus is a sex therapy technique to enhance sexual pleasure for a couple and reduce sexual dysfunction.

Long-Term Outcomes for People with Sexual Dysfunctions

• Positive outcomes correlate with:
  • Good relationship quality
  • High partner motivation
  • Lack of comorbid disorders

Normal Sexual Desires, Paraphilias, and Paraphilic Disorders

• No specific information provided in these slides, only a title slide.

Exhibitionistic Disorder (DSM-5)

• Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one's genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviors.
• The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Specify if sexually aroused by exposing genitals to prepubertal children, mature individuals, or both.
• Specify if in a controlled environment or in full remission.

Fetishistic Disorder (DSM-5)

• Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors.
• The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The fetish objects are not limited to articles of clothing used in cross-dressing (as in transvestic disorder) or devices specifically designed for the purpose of tactile genital stimulation (e.g., vibrator).
• Specify if in a controlled environment or in full remission.
• Specify if body part, nonliving object, or other.

Frotteuristic Disorder (DSM-5)

• Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.
• The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Specify if in a controlled environment or in full remission.
• People with frotteurism prefer crowded places such as subways to seek victims.

Pedophilic Disorder (DSM-5)

• Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally age 13 years or younger).
• The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
• The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A.
• Specify if exclusive to children or nonexclusive, sexually attracted to males or females or both, and limited to incest.
• Specify if in a controlled environment or in full remission.

Sexual Masochism and Sexual Sadism (DSM-5)

• Sexual Masochism Disorder
  • Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or behaviors.
  • The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Sexual Sadism Disorder
  • Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or behaviors.
  • The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Specify if in a controlled environment or in full remission. Specify with asphyxiophilia.

Transvestic Disorder (DSM-5)

• Over a period of at least 6 months, recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or behaviors.
• The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Specify if in a controlled environment or in full remission.
• Specify if with fetishism or autogynephilia.
• People with transvestism cross-dress for sexual excitement, sometimes in public.

Voyeuristic Disorder (DSM-5)

• Over a period of at least 6 months, recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges, or behaviors.
• The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The individual experiencing the arousal and/or acting on the urges is at least 18 years of age.
• Specify if in a controlled environment or in full remission.

Epidemiology of Paraphilic Disorders

• Prevalence (%) and Odds Ratios (Men versus Women) for Desire (Wish to Experience) Paraphilic Behaviors Among 1,040 Adults (475 Men and 565 Women) Surveyed in the General Population (Presented in Descending Order of Prevalence)
  • Voyeurism
    • Men = 60.0
    • Women = 34.7
  • Fetishism
    • Men = 40.4
    • Women = 47.9
  • Exhibitionism (extended)
    • Men = 35.0
    • Women = 26.9
  • Frotteurism
    • Men = 34.2
    • Women = 20.7
  • Masochism
    • Men = 19.2
    • Women = 27.8
  • Sadism
    • Men = 9.5
    • Women = 5.1
  • Transvestism
    • Men = 7.2
    • Women = 5.5
  • Exhibitionism (strict)
    • Men = 5.9
    • Women = 3.4
  • Sex with child
    • Men = 1.1
    • Women = 0.2

Biological and Environmental Risk Factors for Paraphilic Disorders

• Biological Risk Factors - Brain Areas:
  • Frontal lobe
  • Cingulate gyrus
  • Hypothalamus
  • Amygdala
  • Hippocampus
• Environmental Risk Factors:
  • Poor social skills
  • Family variables
  • Learning experience
  • Cognitive distortions

Causes of Paraphilic Disorders

• Biological predisposition toward hypersexuality
• Problematic family environment: Inadequate attachment, maltreatment, poor development of social and sexual skills
• Aberrant learning experiences regarding sexuality: Classical conditioning with odd sexual stimuli, deviant attachment and arousal to children, unusual fantasies reinforced by masturbation
• Maladaptive cognitive and personality patterns: Rationalizations for odd sexual behavior, inability to suppress paraphilic thoughts, antisocial tendencies
• All these may lead to: Possible paraphilia

Prevention of Paraphilic Disorders

• Includes teaching appropriate social and sexual skills.
• Involves providing relapse prevention strategies.

Assessment of Paraphilic Disorders

• Items from the Screening Scale for Pedophilic Interests:
  • Offender has male victim (Yes = 2; No, female victims only = 0)
  • Offender has more than one victim (Yes = 1; No, single victim only = 0)
  • Offender has a victim aged 11 or younger (Yes = 1; No, child victims were 12 or 13 years old = 0)
  • Offender has an unrelated victim (Yes = 1; No, related victims only = 0)

Biological Treatment of Paraphilic Disorders

• Vaginal and rectal perineometers
• A vaginal photoplethysmograph
• A penile strain gauge
• Are all physiological assessment devices for sexual response.

Psychological Treatments of Paraphilic Disorders

• Aversion treatment
• Covert sensitization
• Orgasmic reconditioning

Long-Term Outcomes for People with Paraphilic Disorders

• 78.6 – 95.6% respond positively to treatment.

Gender Dysphoria (DSM-5)

• Gender Dysphoria in Children
  • A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least six of the following (one of which must be Criterion A1):
    • A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one's assigned gender).
    • In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
    • A strong preference for cross-gender roles in make-believe play or fantasy play.
    • A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
    • A strong preference for playmates of the other gender.
    • In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
    • A strong dislike of one's sexual anatomy.
    • A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender.
  • The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Gender Dysphoria in Adolescents and Adults

• A marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least two of the following:
  • A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
  • A strong desire to be rid of one's primary and/or secondary sex characteristics because of a marked incongruence with one's experienced/ expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
  • A strong desire for the primary and/or secondary sex characteristics of the other gender.
  • A strong desire to be of the other gender (or some alternative gender different from one's assigned gender).
  • A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender).
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one's assigned gender).
• Specify with a disorder of sex development and/or posttransition to desired gender.

Gender Dysphoria: Features and Epidemiology

• Young boys and girls typically play apart, but children with gender dysphoria may identify more with the opposite gender.

Biological & Psychological Treatment of Gender Dysphoria

• Caitlyn Jenner has made headlines with her recent gender transition.

Long-Term Outcomes for People with Gender Dysphoria

• Children with gender dysphoria are thought to respond to behavior therapy better than adolescents.
• Youths who continue to show intense cross-gender behavior throughout their childhood may be more likely to develop gender dysphoria, especially for girls.

Chapter Reflections

• What is the impact of the Internet on sexual fantasies and behaviors?
• What separates “normal” sexual activity from "abnormal" sexual activity?
• How would you respond to cross-gender behaviors in your child?