Week 7: Sexual Dysfunctions, Paraphilic Disorders & Gender Dysphoria PDF

Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria What is normal sexuality? Normal vs abnormal sexual behaviour Normative data Cultural considerations Gender differences...

Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria What is normal sexuality? Normal vs abnormal sexual behaviour Normative data Cultural considerations Gender differences Age Sexual and gender dysphoria disorders Sexual dysfunctions Paraphilias Gender dysphoria Overview of sexual dysfunctions Sexual response cycle Desire Arousal Orgasm Males and females can experience parallel versions of most disorders. Sexual dysfunctions Lifelong Acquired Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 1  Generalised Situational Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 2  Prevalence? Must be perceived as distressing Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 3  Sexual desire/arousal disorders Male hypoactive sexual desire disorder Female sexual interest/arousal disorder Erectile dysfunction Male hypoactive sexual desire disorder & female sexual interest/arousal disorder Little to no interest in sexual activity Decreased frequency of: Masturbation Sexual fantasies Intercourse Prevalence: 25% of population Male: 5% (increases with age) Female: 22% (decreases with age) Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 4  Male erectile disorder Difficulty achieving and maintaining an erection. Female arousal disorder Difficulty achieving and maintaining adequate lubrication. Prevalence Males: 5% aged between 18 to 59 (rapidly increases after age 60) Females: 14% Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 5  Estimated prevalence and severity of erectile dysfunction in a sample of 1.290 men between 40 and 70 years old. Orgasm disorders In men: delayed ejaculation 8% report delayed or no ejaculation during sexual interactions In women: condition referred to as female orgasmic disorder Adequate desire and arousal Unable to achieve orgasm Common complaint of adult females (25% report difficulty reaching orgasm) Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 6  Premature ejaculation Before the man or partner wishes to finish (less than a minute) Most prevalent male sexual dysfunction 21% of males affected by it Declines with age Common in younger, inexperienced males Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 7  Sexual pain disorders Genito-pelvic pain/penetration disorder Marker pain during intercourse Extreme pain during intercourse Adequate sexual desire, arousal, orgasm Must rule out medical reasons Vaginismus Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 8  Involuntary pelvic spasms Feelings of ripping, burning, or tearing Prevalence: 6% Assessing sexual behaviour 1. Interviews Clinician must demonstrate comfort Assess multiple dimensions: Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 9  Sexual attitudes Behaviours Sexual response cycle Relationship issues Physical health Psychological disorders 2. Medical Possible medication side effects Physical conditions (refer to GP) 3. Psychophysiological Exposure to erotic material Sexual arousal response Males: penile strain gauge Females: vaginal photoplethysmography (VPG) → measures total blood volume in vaginal tissue (but poor correlation with self-reported sexual arousal) Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 10  Causes of sexual dysfunctions Biological contributions Physical disease → affecting sensation or blood flow to the region Diabetes Obesity Vascular disease Prescription medications → affecting blood flow or sexual desire/arousal SSRIs, TCAs, MAOIs Anti-psychotics Blood pressure medications Alcohol and drugs → suppresses physical responses and sexual desire arousal Psychological contributions “Performance” anxiety Negative feedback → leads to avoidance Negative affect Feelings of unpleasantness and lack of control Low self esteem Cognitive processes Pessimistic thinking errors (e.g.: catastrophising, tunnel vision, attribution bias) Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 11  Social and cultural contributions Negative scripts in childhood from family, religious authorities, or others (e.g.: “you’ll go to hell if you have sex before marriage”) Negative or traumatic experiences Poor interpersonal relationships Lack of communication 💡 Erotophobia: learned negative attitudes about sexuality. Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 12  Treatment of sexual dysfunctions Psychosocial intervention Education (highly effective) Eliminate performance anxiety Sensate focus Non-demand pleasuring Medical interventions (+CBT) Erectile dysfunction Oral tablets (e.g.: Viagra, Levitra, Cialis) Vasodilating Drug injections Surgery (penile prosthesis or implants) Vacuum device therapy Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 13  Paraphilic disorders DSM-5-TR Recurrent, intense sexual urges involving unusual objects, activities, or situations, which cause significant distress or impairment. 💡 DSM-5-TR makes it clear that a person who has a paraphilia may not have a disorder. See textbook page 399 for a discussion of this controversy. Nature of paraphilias Sexual attraction and arousal Socially inappropriate people and/or objects One can have multiple paraphilias (happens often) High co-morbidity Anxiety Mood Substance abuse Associated with: Personal distress about their interest, not merely distress resulting from society’s disapproval or; Having a sexual desire/behaviour that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviours involving unwilling persons or people unable to give legal consent. Clinical descriptions Fetishistic disorder: sexual attraction to non-living objects Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 14  Voyeuristic disorder: observing an unsuspecting individual undressing or naked and to become aroused Exhibitionistic disorder: achieving sexual arousal and gratification by exposing genitals to unsuspecting strangers Frotteuristic disorder: touching or rubbing genitals against non-consenting person in public Transvestic disorder: sexual arousal is strongly associated with the act of (or fantasies of) dressing in clothes of the opposite sex Sexual sadism/masochism: associated with either inflicting pain/humiliation (sadism) or suffering pain/humiliation (masochism) Pedophilic disorder: sexual attraction to children Incest: sexual attraction to family member Explanation of cause Childhood trauma or significant childhood experiences Treatment Psychotherapy to identify underlying cause Prognosis For most paraphilic disorders: 70 to 98% improvement For pedophilic disorders: varies, can be good if insight into motivations (especially problematic if it occurs in combination with antisocial personality disorder) Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 15  💡 Causes for paraphilia are unclear: unlikely to be any single factor… Low levels of arousal to appropriate stimuli Sexual problems Social deficits/inadequate social relations Early dysfunctional experiences Inappropriate arousal/fantasy High sex drive Low suppression of urges and drives Deviant sexual fantasies and reinforcement via orgasm Treatment of paraphilias Efficacy of psychological approaches Success rates vary Unmotivated when no assurance of new routes to sexual gratification Poorest outcomes: rapists / holders of multiple paraphilias Chronic course and high relapse rates 1. Behavioural interventions Target deviant and inappropriate sexual associations Covert extinction (imagining the worst) Orgasmic reconditioning (masturbation + appropriate stimuli) 2. Interpersonal therapy or family/marital therapy 3. Coping and relapse prevention (CBT intervention) Medical treatment Medications Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 16  Antiandrogen medication Chemical castration (eliminates sexual desire and fantasy by reducing testosterone dramatically (Cyproterone acetate) Used on dangerous sexual offenders Efficacy: Greatly reduce desire, fantasy, and arousal High relapse when discontinued Gender dysphoria 💡 The reality that there are more than two sexes (male and female) and genders is not new. All continents on our planet have (or had) cultures with diverse genders,, Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 17  Clinical overview Person feels trapped in the body of the wrong sex Assumes identity of the desired sex Must distinguish from: Transvestic fetishism Differences/disorders of sex development (formerly known as intersexuality or hermaphroditism) Homosexual arousal patterns Statistics Prevalence: rare (around 1.2% of Australian school children have it) Female to male ratio: 1 to 2.3 Rates similar across cultures (status differences) 💡 In the DSM-4, gender dysphoria was named Gender Identity Disorder. Changes from “disorder” to “dysphoria” Continuing controversy Defining features: Strong cross-gender identification and discomfort with biological sex DSM-5 Two criterias: Gender dysphoria in children Gender dysphoria in adolescents and adults DSM-5-TR Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 18  “Desired gender” is now “experienced gender” “Cross-sex medical procedure” is now “gender-affirming medical procedure” “Natal male/natal female” is now “individual assigned male/female at birth Defining gender dysphoria Clinical overview Trapped in the body of the wrong sex. Strong cross-gender identification and discomfort with biological sex Assume the identity of the desired sex (a person's physical sex is inconsistent with the person's gender identity.) Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 19  Goal is not sexual Diagnostic criteria: “A strong and persistent cross-gender identification…” “Persistent discomfort with his or her sex or sense of inappropriateness in the gender of that sex…” Not concurrent with physical intersex condition Clinically significant distress or impairment Controversies Many people diagnosed with GD do not regard their own cross-gender feelings and behaviours as a ‘disorder’. They may question what a ‘normal’ gender identity or ‘normal’ gender role is supposed to be. 💡 One argument is that gender characteristics are socially constructed and therefore naturally unrelated to biological sex. Causes Biological Unclear, but likely genetic contributions 62 to 70% from twin studies Hormones In vitro exposure Brain structure differences? Slightly higher levels of testosterone or estrogen at certain critical periods of development might masculinise a female foetus or feminise a male foetus. Gender dysphoria Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 20  18 to 36 months of age Parental reinforcement Gender non-conformity Gender identity development: transgender Gülgöz et al. (2019) found that transgender children: Strongly identify as members of their current gender group Gender identity and gender-typed preferences generally did not differ from cisgender siblings and controls Patterns of gender development were similar Minimal or no differences in gender identity or preferences based on how long they have lived as their current gender Olsen et al. (2016), Durwood et al. (2016), and Gibson et al. (2021) showed no significant differences or slightly higher levels of depression, anxiety, and self- esteem. In adults, the models are based on a coming-out model (e.g., Bockting & Coleman, 2007), or sexual orientation development model (e.g., Devor, 2004) Treatment (APS) No robust empirical findings demonstrating therapeutic success in directing transgender people to live as the gender normatively expected of the sex they were assigned at birth. A growing body of empirical research has demonstrated that affirming clinical responses can make a significant positive contribution to the mental health of transgender people (Bailey, Ellis & McNeil, 2014; de Vries et al., 2011; Hill et al., 2010; Hyde et al., 2014; Riggs & Due, 2013). As a professional organisation committed to evidence-based practice, the Australian Psychological Society therefore opposes any forms of mental health practice that are not affirming of transgender people. Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 21  Treatment of gender non-conformity in children Work with the child and caregivers to lessen gender dysphoria and decrease cross-gender behaviours “Watchful waiting” Actively affirming and encouraging cross-gender identification Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 22  Gender affirmation surgeries (sex-reassignment surgery) Most invasive. Who is a candidate? – Basic prerequisites before surgery Live in gender-identified role for 1-2 years. Psychologically, financially and socially “stable”. Undergo hormone therapy Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 23  Psychotherapy if deemed necessary by psychotherapist Demonstrated knowledge of logistics and risks of surgery Demonstrable progress in dealing with work, family and interpersonal issues resulting in better state of mental health 75-96% report satisfaction with new identity; 0.47-8% regret ~2% attempt suicide after surgery BUT overall significantly lower rates of suicidal attempts post-gender affirming surgery (e.g., Javier, Crimston & Barlow, 2022; Swan et al., 2023) Lack of social support, discrimination, pressure, etc. Female-to-male conversions adjust better Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 24  Sexual Dysfunctions The lecture begins by discussing the concept of "normal" sexuality, considering normative data, cultural considerations, gender differences, and age. Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 25  Sexual dysfunctions are categorized based on the sexual response cycle: desire, arousal, and orgasm. Dysfunctions can be lifelong or acquired, and generalized or situational. Prevalence of sexual dysfunctions varies, but they must be perceived as distressing to be classified as disorders. Specific Sexual Dysfunctions 1. Desire/Arousal Disorders: Male Hypoactive Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder: characterized by little or no interest in sexual activity. Erectile Dysfunction in males and difficulty maintaining lubrication in females. 2. Orgasm Disorders: Delayed ejaculation in men and female orgasmic disorder in women. Premature ejaculation, most prevalent in younger males. 3. Sexual Pain Disorders: Genito-pelvic pain/penetration disorder, including vaginismus in women. Assessment of Sexual Behavior Involves interviews, medical evaluations, and psychophysiological measures. Importance of clinician comfort and assessing multiple dimensions of sexuality. Causes of Sexual Dysfunctions Biological: Physical diseases, medications, substance use. Psychological: Performance anxiety, negative affect, cognitive processes. Social and Cultural: Negative scripts, traumatic experiences, poor relationships. Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 26  Often involves an interaction of multiple factors (multidimensional view). Treatment of Sexual Dysfunction Psychosocial interventions (e.g., education, sensate focus). Medical interventions (e.g., Viagra for erectile dysfunction). Combination of CBT and medical treatments often used. Paraphilic Disorders Defined as recurrent, intense sexual urges involving unusual objects, activities, or situations causing significant distress or impairment. DSM-5 distinguishes between paraphilias and paraphilic disorders. Types include fetishistic, voyeuristic, exhibitionistic, frotteuristic, transvestic, sadistic/masochistic, and pedophilic disorders. Causes are unclear but may involve multiple factors. Treatment includes behavioural interventions, interpersonal therapy, and medications (e.g., antiandrogen therapy). Gender Dysphoria Characterized by a strong cross-gender identification and discomfort with one's biological sex. Prevalence is rare (~1.2% in Australian school children). DSM-5 changed "Gender Identity Disorder" to "Gender Dysphoria" to reduce stigma. Causes may involve biological factors (genetics, hormones) and environmental influences. Treatment approaches vary, with a growing emphasis on affirming clinical responses. Gender-affirmation (sex-reassignment) surgery is the most invasive treatment option, with specific prerequisites and generally positive outcomes. Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 27  The lecture notes emphasize the complexity of these topics, the importance of evidence-based practice, and the ongoing controversies and evolving understanding in the field. It also touches on cultural and historical perspectives, particularly regarding gender diversity. Week 7: Sexual dysfunctions, paraphilic disorders and gender dysphoria 28