Ch 11 Sexual Disorders and Gender Variations

Question 1

Sexual Dysfunction

Answer 1

• Two general categories of sexual disorders: Sexual Dysfunction and Paraphilic Disorders

SEXUAL DYSFUNCTION – A disorder marked by a persistent inability to function normally in some area of the sexual response cycle. People with sexual dysfunctions have problems with their sexual responses.

• 30% of men and 45% of women suffer from such a dysfunction during their lives

PHASES of SEXUAL RESPONSE:

• Desire, Excitement, Orgasm, and Resolution
• Dysfunction affects one or more of the first three phases.

Difficulty experienced by an individual or couple during any stage of sexual activity, including physical pleasure, desire, preference, arousal, or orgasm

According to the DSM-5 sexual dysfunction requires a person to feel extreme distress and interpersonal strain for a minimum of 6 months

Question 2

Disorders of Desire

Answer 2

DESIRE PHASE – The phase of the sexual response cycle consisting of an urge to have sex, sexual fantasies, and sexual attraction to others.

• Two dysfunctions affect the desire phase:
  
  • MALE HYPOACTIVE SEXUAL DESIRE DISORDER – A male dysfunction marked by a persistent reduction or lack of interest in sex and hence a low level of sexual activity.
  • FEMALE SEXUAL INTEREST/AROUSAL DISORDER – (desire and arousal overlap particularly highly for women) A female dysfunction marked by a persistent reduction or lack of interest in sex and low sexual activity, as well as, in some cases, limited excitement and few sexual sensations during sexual activity.
    
    • Affects as many as 39% of women worldwide.
    • Caused primarily by sociocultural and psychological factors, but biological conditions can also contribute.
• BIOLOGICAL CAUSES
  
  • A high level of the hormone prolactin, a low level of the male sex hormone testosterone, and either a high or low level of the female sex hormone estrogen can lead to low sex drive.
    
    • Ex: Low sex drive has been linked to the high levels of estrogen contained in some birth control pills.
    • Ex: Conversely, it has also been tied to the low level of estrogen found in many postmenopausal women or women who have recently given birth.
  • Sex drive can be lowered by certain pain medications, psychotropic drugs, and illegal drugs such as cocaine and heroin.
  • Low levels of alcohol may enhance the sex drive by lowering a person’s inhibitions, but high levels may reduce it
• PSYCHOLOGICAL CAUSES
  
  • A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women.
  • People with low sexual desire have particular attitudes, fears, or memories that contribute to their dysfunction, such as a belief that sex is immoral or dangerous.
  • Other people are so afraid of losing control over their sexual urges that they try to resist them completely.
  • And still others fear pregnancy.
  • Even a mild level of depression can interfere with sexual desire.
• SOCIOCULTURAL CAUSES
  
  • Essentially, anything that causes undue stress can decrease sexual desire.
    
    • Situational pressures: financial, family, relationships, health, age, neighborhood, war, poverty, etc.
    • History of sexual abuse

The desire phase of the sexual response cycle consists of: an interest in or urge to have sex, sexual attraction to others, and for many people, sexual fantasies

There are 2 dysfunctions that affect the desire phase:

• Male hypoactive sexual desire disorder- persistently lack or have reduced interest in sex and engage in little sexual activity
• Female sexual interest/arousal disorder- This disorder affects both the desire and excitement phases. In DSM-5 it is considered a single disorder because desire and arousal overlap highly for women and many have difficulty distinguishing feelings of desire from those of arousal

Biological Causes- A number of hormones interact to help produce sexual desire and behavior, and abnormalities in their activity can lower a person’s sex drive. In both men and women, a high level of the hormone prolactin, a low level of the male sex hormone testosterone, and either a high or low level of the female sex hormone estrogen can lead to low sex drive.

Psych Causes- A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women. People with low sexual desire have particular attitudes, fears, or memories that contribute to their dysfunction, such as a belief that sex is immoral or dangerous

Sociocultural Causes- Many people who have low sexual desire are feeling situational pressures such as divorce, a death in the family, job stress.

Question 3

Disorders of Excitement

Answer 3

Disorders of Excitement

EXCITEMENT PHASE – The phase of the sexual response cycle marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing.

ERECTILE DISORDER – A dysfunction in which a man repeatedly fails to attain or maintain an erection during sexual activity.

• 15-25% of the male population
• Most men with an erectile disorder are over the age of 50, largely because so many cases are associated with ailments or diseases of older adults.
• Half of all adult men experience erectile difficulty during intercourse at least some of the time. Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes.
• BIOLOGICAL CAUSES
  
  • Any condition that reduces blood flow into the penis, such as heart disease or clogging of the arteries, may lead to erectile disorder. It can also be caused by damage to the nervous system as a result of diabetes, spinal cord injuries, multiple sclerosis, kidney failure, or treatment by dialysis.
  • Absent nightly erections usually (but not always) indicate some physical basis for erectile failure.
• PSYCHOLOGICAL CAUSES
  
  • 90% of all men with severe depression, for example, experience some degree of erectile dysfunction.
  • Cognitive-behavioral theory (Masters and Johnson) says PERFORMANCE ANXIETY and the SPECTATOR ROLE are causes of erectile dysfunction.
    
    • PERFORMANCE ANXIETY – The fear of performing inadequately and a related tension that are experienced during sex.
    • SPECTATOR ROLE – A state of mind that some people experience during sex, focusing on their sexual performance to such an extent that their performance and their enjoyment are reduced.
• SOCIOCULTURAL CAUSES
  
  • Situational Stress such as finances and marital stress are the primary culprits.

The excitement phase of the sexual cycle is described by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing

In men, blood pools in the pelvis and leads to erection of the penis; in women, this phase produces swelling of the clitoris and labia, as well as lubrication of the vagina

Erectile Disorder- Men with this disorder persistently fail to attain or maintain an erection during sexual activity. 15 to 20% of all men are affected

Bio Causes- In addition to the hormonal imbalance discussed before, the more common cause of this disorder is problems with the body’s blood vessels

Psych Causes- Same as desire disorder. As many as 90% of all men with severe depression experience some degree of erectile dysfunction.

SocioCult Causes- Same as desire disorders

Question 4

Disorders of Orgasm

Answer 4

ORGASM PHASE – The phase of the sexual response cycle during which a person’s sexual pleasure peaks and sexual tension is released as muscles in the pelvic region contract rhythmically.

• Dysfunctions of this phase of the sexual response cycle are early ejaculation and delayed ejaculation in men and female orgasmic disorder in women.
• PREMATURE EJACULATION – A dysfunction in which a man persistently reaches orgasm and ejaculates within 1 minute of beginning sexual activity with a partner and before he wishes to. Also called early or rapid ejaculation.
  
  • 30% of men worldwide
  • BIOLOGICAL FACTORS – THREE THEORIES:
    
    • Some men are born with a genetic predisposition to develop this dysfunction.
      
      • 91% of a small sample of men suffering from early ejaculation had first-degree relatives who also had the dysfunction.
    • The brains of men who ejaculate prematurely contain certain serotonin receptors that are overactive and others that are underactive.
    • Men with this dysfunction have greater sensitivity or nerve conduction in the area of their penis, a notion that has received inconsistent research support thus far.
• DELAYED EJACULATION – A male dysfunction characterized by persistent inability to ejaculate or very delayed ejaculations during sexual activity with a partner.
  
  • PSYCHOLOGICAL CAUSE – appears to be performance anxiety and the spectator role. Once a man begins to focus on reaching orgasm, he may stop being an aroused participant in his sexual activity and instead become an unaroused, self-critical, and fearful observer.
  • Finally, delayed ejaculation may develop out of MALE HYPOACTIVE SEXUAL DESIRE DISORDER – A man who engages in sex without any real desire for it may not get aroused enough to ejaculate.
• FEMALE ORGASMIC DISORDER – A dysfunction in which a woman persistently fails to reach orgasm, has very low-intensity orgasms, or has very delayed orgasms.
  
  • 10% or more of women have never had an orgasm.
  • Women who are more sexually assertive tend to have orgasms more regularly.
  • Because arousal plays a key role in orgasms, arousal difficulties often are featured prominently in explanations of female orgasmic disorder.
  • BIOLOGICAL CAUSES
    
    • Diabetes, Multiple Sclerosis, some drugs, postmenopausal, genital structure.
    • In 1854, a medical textbook labeled the female Pelvic Region as the “Region of Insanity”. Lol.
  • PSYCHOLOGICAL CAUSES
    
    • Women with a high level of sexual inhibition are particularly likely to experience female orgasmic disorder.
    • Also caused by depression and memories of childhood traumas.
    • PROTECTIVE FACTORS – Childhood memories of a dependable father, a positive relationship with one’s mother, affection between the parents, the mother’s positive personality, and the mother’s expression of positive emotions were all predictors of positive orgasm outcomes.
  • SOCIOCULTURAL CAUSES
    
    • Many women with both arousal and orgasmic difficulties report that they had an overly strict religious upbringing, were punished for childhood masturbation, received no preparation for the onset of menstruation, were restricted in their dating as teenagers, and were told that “nice girls don’t”.
    • However, a sexually restrictive history is just as common among women who function well during sexual activity.
    • Why, then, do some women and not others develop such problems? Researchers suggest that the difference may involve unusually stressful events or traumas that may help produce the fears, memories, and attitudes that often characterize these sexual problems. For example, many women molested as children or raped as adults have the disorder.

Orgasm Phase- A person’s sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract. The man’s semen is ejaculated and the outer third of a women’s vaginal wall contracts.

There are 2 disorders for men and 1 for women:

• Early ejaculation- persistently reaches orgasm and ejaculates within

1 minute of beginning sexual activity with a partner and before he wishes to. 30 percent of men worldwide are affected

• Delayed ejaculation- persistently is unable to ejaculate or has very delayed ejaculations during sexual activity with a partner. 10% men worldwide are affected
• Female orgasmic disorder- female equivelent of delayed ejaculation. Affects about 21% of women

Question 5

Disorders of Sexual Pain

Answer 5

Disorders of Sexual Pain

GENITO-PELVIC PAIN/PENETRATION DISORDER – A sexual dysfunction characterized by significant physical discomfort during intercourse.

• Women suffer this dysfunction much more than men.
• VAGINISMUS – The muscles around the outer third of the vagina involuntarily contract, preventing entry of the penis. They engage in sex but fear the discomfort of penetration of the vagina.
• Usually a learned fear response, set off by a woman’s expectation that intercourse will be painful and damaging.
• Alternatively, the disorder can be caused by an infection of the vagina or urinary tract, or a gynecological disease such as herpes.
• DYSPAREUNIA – experience severe vaginal or pelvic pain during sexual intercourse.
  
  • This usually has a physical cause – like an injury (for example, to the vagina or pelvic ligaments) during childbirth.
  • 1-5% of men suffer from pain in the genitals during intercourse, and many of these men also qualify for a diagnosis of genito-pelvic pain/penetration disorder

Question 6

Treatments for Sexual Dysfunctions

Answer 6

What Are the General Features of Sex Therapy?

• Modern sex therapy is short-term and instructive, typically lasting 15 to 20 sessions. It centers on specific sexual problems rather than on broad personality issues.

Sex therapy follows the general steps:

1. Assessing and conceptualizing the problem. Patients are initially given a medical examination and are interviewed concerning their “sex history.”
2. Mutual responsibility. Both partners in the relationship share the sexual problem, both are in therapy.
3. Education about sexuality.
4. Emotion identification. Patients identify and express upsetting emotions tied to past events that may keep interfering with sexual arousal and enjoyment
5. Attitude change. Change any beliefs about sexuality that are preventing sexual arousal and pleasure.
6. Elimination of performance anxiety and the spectator role. Therapists often teach couples sensate focus or nondemand pleasuring.
7. Increasing sexual and communication skills.
8. Changing destructive lifestyles and couple interactions.
9. Addressing physical and medical factors.

What Techniques Are Used to Treat Particular Dysfunctions?

TREATING DISORDERS OF DESIRE

• Male hypoactive sexual desire disorder and female sexual interest/arousal disorder are among the most difficult dysfunctions to treat because of the many issues that may feed into them.
• Therapists use a combination of techniques:
  
  • AFFECTUAL AWARENESS – patients visualize sexual scenes in order to discover any feelings of anxiety, vulnerability, and other negative emotions
  • COGNITIVE SELF-INSTRUCTION – help them change their negative reactions to sex.
  • BEHAVIORAL APPROACHES – Keep a diary to track thoughts and feelings.
  • BIOLOGICAL TREATMENT – hormone treatments.
• ERECTILE DISORDER – Focus on reducing a man’s performance anxiety.
  
  • Biological Approaches – Viagra, Cialis, Levitra, Stendra – the most common form of treatment.
• PREMATURE EJACULATION – stop-start, or pause, procedure
  
  • Sometimes treated with SSRI’s – Serotonin-enhancing Antidepressants.
• DELAYED EJACULATION – techniques to reduce performance anxiety and increase stimulation.
• FEMALE ORGASMIC DISORDER – A sex therapy approach that teaches women with female arousal or orgasmic problems how to masturbate effectively and eventually to reach orgasm during sexual interactions.
• GENITO-PELVIC PAIN/PENETRATION DISORDER – Two Approaches:
  
  • Practice tightening and relaxing her vaginal muscles until she gains more voluntary control over them.
  • Gradual behavioral exposure treatment to help her overcome her fear of penetration.
    
    • both forms of genito-pelvic pain/penetration disorder are best assessed and treated by a team of professionals, including a gynecologist, physical therapist, and sex therapist or other mental health professional.

Question 7

Paraphilic Disorders

Answer 7

• PARAPHILLIC DISORDERS – People with paraphilic disorders have repeated and intense sexual urges or fantasies in response to objects or situations that society deems inappropriate.
  
  • Not so uncommon.
  • EXHIBITIONISTIC DISORDER – paraphilic pattern in which people act on urges to expose their genitals to others.
  • People who sext to strangers or other nonconsenting recipients are more likely to have general problems with attachment or intimacy than other people.
  • ANTIANDROGENS – lower the production of testosterone, the male sex hormone, and reduce the sex drive.
  • The definitions of these disorders, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur.
  • Some clinicians argue that except when other people are hurt by them, at least some paraphilic behaviors should not be considered disorders at all.
  • Keep in mind that for years clinicians considered homosexuality a paraphilic disorder, and their judgment was used to justify laws and even police actions against gay people.

Question 8

Fetishistic Disorder

Answer 8

FETISHISTIC DISORDER – A paraphilic disorder consisting of recurrent and intense sexual urges, fantasies, or behaviors that involve the use of a nonliving object or nongenital part, often to the exclusion of all other stimuli, accompanied by clinically significant distress or impairment.

• Not been able to pinpoint the causes of fetishistic disorder.
• Cognitive-behavioral theorists propose that fetishes are acquired through classical conditioning (Association).
• Treated fetishistic disorder with Aversion Therapy.

Question 9

Transvestic Disorder

Answer 9

TRANSVESTIC DISORDER (TRANSVESTISM, CROSS-DRESSING) – A paraphilic disorder consisting of repeated and intense sexual urges, fantasies, or behaviors that involve dressing in clothes of the opposite sex, accompanied by clinically significant distress or impairment.

• He may be the picture of characteristic masculinity in everyday life and is usually alone when he cross-dresses.
• Acquired through classical conditioning.
• Transvestic disorder is often confused with transgender feelings and behaviors, but, as you will see, they are two separate patterns that overlap only in some individuals.
  
  • TRANSVESTIC DISORDER – is about the sexual arousal certain persons feel when they dress in opposite-gender clothes.
  • TRANSGENDER FUNCTIONING – is about the gender a person considers himself or herself to be.

Question 10

Exhibitionistic Disorder

Answer 10

EXHIBITIONIST DISORDER – A paraphilic disorder in which persons have repeated sexually arousing urges or fantasies about exposing their genitals to others, and either act on these urges with nonconsenting individuals or experience clinically significant distress or impairment.

• Wants to provoke shock or surprise rather than initiate sexual activity with the victim.
• Those with the disorder are typically immature in their dealings with the opposite sex and have difficulty in interpersonal relationships

Question 11

Voyeuristic Disorder

Answer 11

VOYEURISTIC DISORDER – A paraphilic disorder in which a person has repeated and intense sexual desires to observe unsuspecting people in secret as they undress or to spy on couples having intercourse, and either acts on these urges with nonconsenting people or experiences clinically significant distress or impairment.

• The clinical disorder of voyeuristic disorder is marked by the repeated invasion of other people’s privacy.

Question 12

Frotteuristic Disorder

Answer 12

FROTTEURISTIC DISORDER – A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies that involve touching and rubbing against a nonconsenting person, and either acts on these urges with the nonconsenting person or experiences clinically significant distress or impairment.

Question 13

Pedophilic Disorder

Answer 13

PEDOPHILIC DISORDER – A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies about watching, touching, or engaging in sexual acts with children, and either acts on these urges or experiences clinically significant distress or impairment.

• Some were themselves sexually abused as children, and many were neglected, excessively punished, or deprived of genuinely close relationships during their childhood.
• This leads them to seek an area in which they can be masters.
• Most men with pedophilic disorder also display at least one additional psychological disorder.
• Treatment for Pedophiles includes Aversion Therapy, masturbation satiation, cognitive-behavioral therapy, and antiandrogen drugs.
  
  • Relapse-prevention training is modeled after the relapse-prevention training programs used in the treatment of substance use disorders.

Question 14

Sexual Masochism and Sadism Disorders

Answer 14

SEXUAL MASOCHISM DISORDER – A paraphilic disorder in which a person has repeated and intense sexual urges, fantasies, or behaviors that involve being humiliated, beaten, bound, or otherwise made to suffer, accompanied by clinically significant distress or impairment.

• Learned through classical conditioning.
• HYPOXYPHILIA – people strangle or smother themselves (or ask their partner to strangle them) in order to enhance their sexual pleasure
• AUTOEROTIC ASPHYXIA – people, usually males and as young as 10 years old, may accidentally induce a fatal lack of oxygen by hanging, suffocating, or strangling themselves while masturbating.

SEXUAL SADISM DISORDER – A paraphilic disorder in which a person has repeated and intense sexual urges or fantasies that involve inflicting suffering on others, and either acts on these urges with nonconsenting individuals or experiences clinically significant distress or impairment.

• Often their sadism becomes more and more severe over the years.
• Can be a danger to others.
• Believed to be learned through classical conditioning. The disorder may result from modeling, when adolescents observe others achieving sexual satisfaction by inflicting pain. The many Internet sex sites and sexual videos, magazines, and books in our society make such models readily available.
• People with sexual sadism disorder inflict pain in order to achieve a sense of power or control, necessitated perhaps by underlying feelings of sexual inadequacy.
• Treated with Aversion Therapy.

Question 15

Transgender and Gender Dysphoria

Answer 15

TRANSGENDER – Individuals who have a strong sense that their gender identity is different from their birth anatomy.

• Estimated 25 million people in the world are transgender 0.08% of the adult population

GENDER DYSPHORIA – A disorder in which a person persistently feels clinically significant distress or impairment due to his or her assigned gender and strongly wishes to be a member of another gender.

• The DSM-5 categorization of gender dysphoria is controversial. Many argue that since a transgender pattern reflects an alternative – not pathological – way of experiencing one’s gender identity, it should never be considered a psychological disorder.
• In its first two editions, the developers of the DSM listed homosexuality as a sexual disorder, such as a paraphilic disorder.

Transgender Functioning = does NOT represent a mental disorder.

• Transgender women (that is, people who identify as female but were assigned male at birth) outnumber transgender men (people who identify as male but were assigned female at birth)
• Transgender adults may have had transgender feelings when they were children, but many children with transgender feelings do not become transgender adults.
• Surveys of mothers indicate that about 1.5 percent of young boys wish to be a girl, and 3.5 percent of young girls wish to be a boy, yet, less than 1 percent of adults are transgender.
• This age shift is, in part, why many experts on transgender functioning strongly recommend against any form of irreversible physical procedures for this pattern until the individual is at least 14 to 16 years of age.
• Biological factors – perhaps genetic or prenatal – are key to transgender functioning. Consistent with a genetic explanation, transgender functioning does sometimes run in families.
  
  • In a study of Identical twins found that when one of the twins was transgender, the other twin was as well in 9 out of 23 pairs.
  • Also, using MRI scanning, one team of researchers found that the brains of transgender men (people who identify as male but were assigned female at birth) have relatively thin subcortical areas, much like those of nontransgender men, and the brains of transgender women (people who identify as female but were assigned male at birth) have relatively thin cortical regions in the right hemisphere, much like those of nontransgender women.
  • Similar results have been uncovered in studies of brain reactions to strong unpleasant odors. In general, male and female brains react to strong smells differently, particularly in the hypothalamus. Here again, transgender studies have found that, when exposed to strong unpleasant smells, the hypothalamic responses of transgender males are similar to those of nontransgender males, whereas the hypothalamic responses of transgender females are similar to those of nontransgender females. Brain response similarities between transgender individuals and their nontransgender counterparts have likewise been found in studies that expose participants to certain sounds, visual stimuli, and memory challenges.
  • TRANSGENDER BRAIN – Based on such findings, it might be tempting to conclude that transgender people are individuals whose male brain is simply trapped inside a female body or whose female brain is trapped inside a male body, but, as researcher Antonio Guillamon cautions, “Trans people have brains that are different from males and females, a unique kind of brain”. That is, they do not have a male or female brain, but rather a transgender brain.
• OPTIONS FOR TRANSGENDER
  
  • HORMONE ADMINISTRATION – Estrogen for females, Testosterone for males.
  • GENDER REASSIGNMENT SURGERY (or GENDER CHANGE SURGERY) – A surgical procedure that changes a person’s sex organs and gender features. Also known as gender change surgery.
    
    • 70% of patients report satisfaction with the outcome of the surgery, improvement in the quality of their lives, a better psychological state.

Gender Dysphoria

GENDER DYSPHORIA – A disorder in which a person persistently feels clinically significant distress or impairment due to his or her assigned gender and strongly wishes to be a member of another gender.

• Most transgender people do indeed report that the incongruence between their gender identity and birth anatomy directly causes them some distress.
• HOWEVER, surveys suggest that the primary cause for intense dysphoric reactions is the enormous prejudice that transgender persons typically face.
  
  • Ex: 80-90% of transgender people have been harassed or attacked in their schools, workplaces, or communities (some have even been murdered).
    
    • 50% have been fired from a job, not hired, or not promoted
    • 20% have been denied a place to live
    • Many have been stigmatized, excluded from social groups, and denied access to appropriate health care (both general health care and care related to their gender needs)
    • This is why so many clinicians favor the elimination of gender dysphoria from the DSM. That is, society’s reactions to a transgender person may be much more responsible for the individual’s psychological pain than the individual’s dismay over transgender issues themselves.
      
      • When transgender individuals are supported in their identities by their family members and friends, they typically do not experience significant mental health problems.
• INTERVENTIONS
  
  • The greatest help to people with gender dysphoria are the biological gender-change procedures that so many transgender persons undergo.
    
    • In an analysis of 28 studies – with a total of 1,833 transgender individuals who received hormone therapy and/or gender reassignment surgery, it was found that 80% experienced significant improvements in their symptoms of gender dysphoria as a result of the biological interventions.
  • Support groups have also been shown to be helpful.