Lecture 8

Question 1

When was homosexuality removed from the DSM-II

Answer 1

1974

Question 2

What percentage of men and women experience symptoms of sexual dysfunction

Answer 2

31% of men and 43% of women

Question 3

What are the sexual interest/desire/arousal dysfunctions in males and females

Answer 3

Males: Male hypoactive sexual
desire disorder, Erectile disorder
Females: Female sexual interest
arousal disorder

Question 4

What are the orgasm dysfunctions in males and females

Answer 4

Males: Premature ejaculation
disorder, Delayed ejaculation disorder
Females: Female orgasmic disorder

Question 5

What are the sexual pain dysfunctions in males and females

Answer 5

Males: None
Females: Genito-pelvic
pain/penetration disorder

Question 6

What are the specifiers for sexual dysfunctions

Answer 6

• lifelong vs acquired
• generalised vs situational
• mild, moderate, or severe

Question 7

What are the ABCD characteristics of Male Hypoactive Sexual Desire Disorder

Answer 7

A) Persistently or recurrently deficient or absent sexual/erotic
thoughts or fantasies and desire for sexual activity

B) The symptoms have persisted for a minimum duration of
approximately 6 mos.

C) The symptoms cause clinically significant distress in the
individual

D) The symptoms are not better accounted for by a nonsexual
mental disorder or 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

Question 8

What percentage of men are affected by Male Hypoactive Sexual Desire Disorder

Answer 8

5%

Question 9

John is a 45-year old man who has difficulty obtaining an erection when his wife initiates sex. John hasn’t initiated sex with his wife in years and he wishes his wife would stop expecting him to have sex. John’s wife is unhappy with their life in the bedroom and often asks John if he is having an affair because it isn’t normal for a man to not want sex. John is not having an affair, rather he says he has no desire to have sex with his wife or anyone. He feels stressed at work and isn’t as satisfied with his physical appearance as he was when he was 20 and exercising regularly. John feels he wouldn’t be bothered by his lack of interest in sex if his wife weren’t bothered by it. What might John be suffering with?

Answer 9

Male Hypoactive Sexual Desire Disorder

Question 10

What are the ABCD characteristics of Female Sexual Interest/Arousal Disorder

Answer 10

A) Lack of or significantly reduced sexual interest/arousal, as manifested by 3+ of the
following:
1. Absent/reduced sexual activity
2. Absent/reduced sexual/erotic thoughts or fantasies
3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempt to initiate
4. Absent/reduced sexual excitement/pleasure during sexual activity in 75-100% of
sexual encounters
5. Absent/reduced sexual interest/arousal in response to any internal or external
sexual/erotic cues
6. Absent/reduced genital or non-genital sensations during sexual activity in 75-100% of sexual encounters

B) The symptoms have persisted for a minimum duration of approximately 6 mos

C) The symptoms cause clinically significant distress in the individual

D) The symptoms are not better accounted for by a nonsexual mental disorder or 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

Question 11

Cheryl is 35 years old. She rarely thinks about having sex, does not
initiate sex with her husband, and wishes he would stop trying to have sex with her. Cheryl used to enjoy sex quite a bit, both before and after she was married. But now that she has had children, she feels that sex is not important. She has better things to do, like sleep, than have sex.
However, even if she feels rested, she is uninterested in sex. When she does give into her husband, she doesn’t feel any enjoyment no matter what he does in the bedroom. Afterwards, she may have even less interest in sex, if that were possible. She loves her husband, but doesn’t feel any passion for him. She doesn’t think she could feel passion for any man. Cheryl’s husband is quite unsatisfied with their sex life and wants Cheryl to get help. Cheryl just wants her husband to have an affair so that he will stop asking her to have sex. What condition is Cheryl likely facing?

Answer 11

Female Sexual Interest/Arousal Disorder

Question 12

What percentage of women experience disinterest in sex for at least a few months

Answer 12

25%-43%

Question 13

What are the ABCD Characteristics of Erectile Disorder

Answer 13

A) At least one of the following must be experienced 75-100% of sexual activity occasions
1. Marked difficulty in obtaining an erection during sexual activity
2. Marked difficulty in maintaining an erection until the completion of sexual activity
3. Marked decrease in erectile rigidity

B) The symptoms have persisted for a minimum duration of approximately 6 mos.

C) The symptoms cause clinically significant distress in the individual

D) The symptoms are not better accounted for by a nonsexual mental disorder or 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

Question 14

What is the prevalence of erectile disorder

Answer 14

50-60% of men may experience at least occasional erectile dysfunction
- Prevalence increases with age

Question 15

Gary has sought treatment at a sex therapy clinic because he has difficulty maintaining an erection when having sex with his wife. He experiences initial interest in having sex, but then quickly loses interest almost immediately upon entering his wife. He did not have this issue when he first started dating his wife. During his interview, Gary admitted
that he and his wife do not communicate well and that he
feels they spent too much time together. He doesn’t know how to tell her that he wants to spend more time with his friends and this causes him stress. What condition is Gary likely facing?

Answer 15

Erectile Disorder

Question 16

What are the ABCD Characteristics of Female Orgasmic Disorder

Answer 16

A) Presence one of the following during 75-100% of sexual activity
occasions:
1. Marked delay in, marked frequency of, or absence of orgasm
2. Markedly reduced intensity of orgasmic sensations

B) The symptoms have persisted for a minimum duration of approximately 6 mos.

C) The symptoms cause clinically significant distress in the individual

D) The symptoms are not better accounted for by a nonsexual mental disorder or 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

Question 17

What is the prevalence of women who experience issues with achieving orgasm

Answer 17

17%-41% have trouble
2/3 women have faked an orgasm

Question 18

Anne is a 26-year old woman who sought treatment after her partner became concerned that she could not achieve an orgasm. Anne was quite happy with her relationship with Colin and enjoyed their sex life, although she too wished she could experience orgasms. Upon questioning, Anne reported that she feels anxious about letting go in the bedroom and fully relaxing. She reported that she has
never felt quite comfortable with her body and has rarely masturbated. What issue is Anne likely facing?

Answer 18

Female Orgasmic Disorder

Question 19

What are the ABCD Characteristics of Premature Ejaculation Disorder

Answer 19

A) Persistently or recurrently pattern of ejaculation occurring during partnered sexual activity within 1 minute following vaginal penetration and before the individual wishes it

B) The symptoms have persisted for a minimum duration of approximately 6 mos. AND must be experienced on 75-100% of sexual activity occasions

C) The symptoms cause clinically significant distress in the individual

D) The symptoms are not better accounted for by a nonsexual mental disorder or 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

Question 20

What is the prevalence of Premature Ejaculation Disorder

Answer 20

Only 3% of men meet diagnostic criteria for PED
- But 21% of men are affected at least occasionally
- Most common in younger, inexperienced males

Question 21

What are the ABCD Characteristics of Delayed Ejaculation Disorder

Answer 21

A) At least one of the following must be experienced 75-100% of
sexual activity occasions
1. Marked delay in ejaculation
2. Marked infrequency in ejaculation

B) The symptoms have persisted for a minimum duration of
approximately 6 mos.

C) The symptoms cause clinically significant distress in the
individual

D) The symptoms are not better accounted for by a nonsexual
mental disorder or 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

Question 22

What is the prevalence of Delayed Ejaculation Disorder

Answer 22

Affects <1% of all adult men

Question 24

What are the Immediate and Distal causes of sexual dysfunction

Answer 24

Immediate: Spectator role and fears about performance
Distal: Religious orthodoxy, psychosexual trauma, homosexual inclination, inadequate counselling, excessive alcohol intake, physiological problems, sociocultural factors

Question 25

What are some biological predictors of sexual dysfunctions

Answer 25

• Smoking
• Heavy drinking
• Cardiovascular problems
• Diabetes
• Neurological diseases
• Low physiological arousal
• SSRI medications
• Antihypertensive medication
• Drug use

Question 26

What are some psychological predictors of sexual dysfunctions

Answer 26

• Depression
• Anxiety
• Poor self-esteem
• Uncomfortable environment for sex
• Rigid, narrow attitudes about sex
• Negative thoughts about sex
• Being overly dependent on routines

Question 27

What are some sociocultural predictors of sexual dysfunctions

Answer 27

• Rape or sexual abuse
• Erotophobia: Associate sexuality with negative feelings,
  anxiety, or threat
• Relationship problems
• Long periods of abstinence
• History of hurried sex

Question 28

What are the treatment methods for sexual dysfunctions

Answer 28

General Treatment methods:
- education e.g. on sexual interactions, sexual disorders, etc.
- couples therapy when relationship problems exist
- communication training (likes/dislikes)
- Masters and Johnson’s psychosocial intervention

More Specific Treatment Methods
- Premature ejaculation: squeeze technique
- Female orgasm disorder: masturbatory training
- Vaginismus: use of dilators
- Low sexual desire problems: exposure to erotic material
- Erectile dysfunction: viagra (not great, can cause side effects so many discontinue use), injection of vasodilating drugs into the penis, vacuum device therapy, penile device or implants

Question 29

What is involved in the Masters and Johnson’s psychosocial intervention

Answer 29

Duration: treatment daily for 2 weeks
Goal: to eliminate performance anxiety and focus on the self
Content: education about sexual response, foreplay, etc.
Sensate focus and non-demand pleasuring :
* Sexual activity with the goal of focusing on sensations without
trying to achieve orgasm
* Phase I: Refrain from intercourse and genital caressing—
simply explore and enjoy kissing, hugging, massaging, etc
* Phase II: Genital pleasuring, but orgasm and intercourse or
banned
* Phase IIIA: Begin penetration—limit depth and time—continue
with non-genital pleasuring
* Phase IIIB: Resume full intercourse and thrusting

Question 30

Fill in the blank: Paraphilic Disorders are misplaced ____?

Answer 30

Paraphilic Disorders are misplaced sexual attraction and arousal

Question 31

What are Characteristics of Paraphilic Disorders

Answer 31

• Focused on inappropriate people or objects
• Often multiple paraphilic patterns of arousal
• Manifest in fantasies, urges, arousal or behaviors
• Paraphilia is only considered disordered when the
  individual either 1) experiences clinically significant distress or
  impairment OR 2) acts on urges with a non-consenting person

Question 32

What is the prevalence, onset and comorbidity of most paraphilic disorders

Answer 32

Prevalence:
- Most occur in males

Onset:
- Most begin in adolescence
- However, sexual sadism and sexual masochism tend to start by early adulthood

Comorbidity:
- High comorbidity among the paraphilias
- High comorbidity with anxiety, mood, and substance use
disorders

Question 33

What are the AB characteristics of Frotteuristic Disorder

Answer 33

A) Over a period of 6 mos, recurrent and intense sexual
arousal from touching or rubbing against a non-consenting person, as manifested by fantasies,
urges, or behaviours

B) The individual has acted on these sexual urges with a
non-consenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Question 34

What are the ABC characteristics of Fetishistic Disorder and what must be specified

Answer 34

A) Over a period of 6 mos, recurrent and intense sexual
arousal from either the use of nonliving objects or a highly specific focus on non-genital body part(s) (e.g. rubber, hair, feet, objects such as shoes), as manifested by fantasies, urges, or behaviours

B) The fantasies, sexual urges or behaviours cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C) The fetish objects are not limited to articles of clothing
used in cross-dressing or devices specifically designed for the purposes of tactile genital stimulation

Must specify if: body part(s), non-living object(s), other

Question 35

What are the ABC characteristics of Voyeuristic Disorder

Answer 35

A) Over a period of 6 mos, recurrent and intense sexual
arousal from observing an unsuspecting person who is
naked, in the process of derobing, or engaging in sexual activity, as manifested by fantasies, urges, or
behaviours

B) 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

C) The individual experiencing the arousal and/or acting on the urges is at least 18 years old

Question 36

What are some key aspects of the nature of voyeuristic disorder

Answer 36

• The risk associated with ‘peeping’ may intensify sexual
  arousal
• Someone undressing for the voyeur’s benefit is not
  gratifying (i.e, voyeur likes the individual to be unknowing)
• Orgasm is achieved by masturbation, either while
  watching or later while remembering the peeping

Question 37

What are the AB Characteristics of Exhibitionistic Disorder and what must be specified

Answer 37

A) Over a period of 6 mos, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges, or behaviours

B) 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

Must specify if:
- sexually aroused by exposing genitals to prepubertal children
- sexually aroused by exposing genitals to physically mature
individuals
- sexually aroused by exposing genitals to prepubertal children and physically mature individuals

Question 38

What are some key aspects of the nature of Exhibitionistic Disorder

Answer 38

• The element of thrill and risk is necessary for sexual arousal
• Have a desire to shock the individual
• Most masturbate during the exposure
• Might be a type of compulsion: i.e. Exposure may be repeated often and in the same
  place at the same time of day but may feel remorseful afterwards

Question 39

What are the AB Characteristics of Transvestic Disorder and what must be specified

Answer 39

A) Over a period of 6 mos, recurrent and intense sexual arousal from cross-dressing, as manifested by fantasies, urges, or
behaviours

B) The fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Must specify: if with fetishism, and if with autogynephilia

Question 40

What are the AB Characteristics of Sexual Masochism Disorder and what must be specified

Answer 40

A) Over a period of 6 mos, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges, or
behaviours

B) The fantasies cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning

Must specify if: with asphyxiophilia

Question 41

What are the AB Characteristics of Sexual Sadism Disorder

Answer 41

A) Over a period of 6 mos, recurrent and intense sexual arousal from the physical or psychological suffering of another
person, as manifested by fantasies, urges, or behaviours

B) 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

Question 42

What are the ABC Characteristics of Pedophilic Disorder and what must be specified

Answer 42

A) Over a period of 6 mos, recurrent and intense sexual arousing fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child or children (generally age 13 and younger)

B) The individual has acted on these sexual urges, or the sexual
urges or fantasies cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning

C) The individual is at least 16 years of age and at least 5 years older than child/children

Must specify if:
- exclusive type (attracted only to children) or nonexclusive type
- sexually attracted to males, females or both

Question 43

What are some key aspects of the nature of Pedophilic Disorder

Answer 43

• In some cases, pedophilic urges are limited to incest
• Incestuous males may be aroused by adult women
• Male pedophiles are usually not aroused by adult women
• Generally molest children they know
• Physically force rarely used as they violate trust of the
  victim
• Some rationalize the behavior: e.g. consider pedophilic activity to be an act of affection or a teaching experience

Question 44

What are some causes of Paraphilia Disorders

Answer 44

• 2/3 of sex offenders have a history of child sexual abuse
• Heightened impulsivity combined with poor emotion regulation
• Hostile attitudes and lack of empathy toward women (related
  to nonconsensual behaviours with women)
• Cognitive distortions (e.g., the woman wants me to see her
  undress, the child wants me to teach him about sex, she
  deserved to be taught a lesson)
• High sex drives
• Conditioning
• Stimuli and sexual fantasies present during masturbation
  may become paired with sexual arousal

Question 45

What are some treatment methods for Paraphilia Disorders

Answer 45

1) Aversion therapy = Pair their paraphilic fantasies with an aversive stimulus

2) Covert sensitization = Imagine aversive consequences to form negative associations with deviant (e.g., pedophilic) behavior

3) Orgasmic reconditioning = masturbation to appropriate
(adult) stimuli

4) Medications -
- Cyproterone acetate (“chemical castration”) reduces desire and fantasy dramatically, but they
return after drug removal
- Depo-Provera reduces testosterone
-

Question 46

What is Gender Dysphoria

Answer 46

Community definition: gendered experiences (e.g. social or bodily
experiences) incongruent with current gender

Professional definition: When a person experiences distress
resulting from incongruence between current gender and
assigned gender at birth

Question 47

What are the AB Characteristics of Gender Dysphoria in Adolescents and Adults and what must be specified

Answer 47

A) 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:
1. 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)
2. 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)
3. A strong desire for the primary and/or secondary sex characteristics of the another
gender
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. 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)

B) The condition is associated with clinically significant distress or impairment
in social, occupational, or other areas of functioning

Must specify if:
- with a disorder of sex development
- Posttransition (The individual has transitioned to full-time living in the desired gender and has
undergone (or is preparing to have) at least one cross-sex medical procedur/treatment (e.g. cross-sex hormone treatmen, gender reassignment surgery etc.)

Question 48

What are the AB Characteristics of Gender Dysphoria in Children and what must be specified

Answer 48

A) 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):
1. 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).
2. 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.
3. A strong preference for cross-gender roles in make-believe play or fantasy play.
4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. 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.
7. A strong dislike of one’s sexual anatomy.
8. A strong desire for the primary and/or secondary sex characteristics that match
one’s experienced gender.

B) The condition is associated with clinically significant distress or impairment
in social, occupational, or other areas of functioning

Must Specify if: with a disorder of sex development

Question 49

What is the causes of gender dysphoria

Answer 49

No clear biological causes identified, but likely has
genetic component
- Studies have found that 62 to 70% of variance in
gender expression is explained by genetics

Question 50

What are the associated psychopathology with gender dysphoria

Answer 50

In a systematic review of individuals:
- 53.2% had a lifetime Axis I disorder
- Mood disorders (42.1% lifetime)
- Anxiety disorders (26.8% lifetime)
- Depression among young people aged 12-29 (50.6% transgender, 20.6% cisgender; N=360)
- Prescription of puberty blockers during adolescence decreased lifetime odds of suicidal ideation among transgender individuals

Question 51

What are the treatment options for gender dysphoria

Answer 51

Social affirmations
* Least invasive and adaptable
* Correct pronoun and name use
* Clothing and hairstyles

Legal affirmation
* Legal change of name and/or gender marker on documentation, e.g. drivers license

Medical Treatment
Gender affirmation surgeries
* Genital reconfiguration, facial surgery, vocal surgery

• Hormone therapies
• Hormone replacement therapies (HRT): masculinising and feminising hormones
• Hormone blockers (or puberty blockers): prevent the release of hormones and can delay the onset of puberty

Question 52

How does treatment for gender dysphoria vary by age?

Answer 52

For children: Social transition most appropriate, schools are important place to ensure affirmative environment

For Adolescents: Puberty blockers can delay the onset of puberty (and are also
prescribed for cisgender children with early onset puberty) however they require a gender dysphoria diagnosis, fertility preservation counselling and consent from guardian, for adolescents to access these blockers
- Hormone replacement therapies (HRT) not medically applicable until later adolescence or adulthood, Surgeries only accessible in adulthood

For Adults: No diagnosis required to access hormonal therapies, Mix of treatments are often appropriate