Sexual Dysfunctions

Question 1

Sexual Dysfunctions

Answer 1

Gender-Specific sexual dysfunctions have been added to DSM 5

1. Female Sexual Interest/Arousal Disorder (new)
   
   1. Sexual Aversion Disorder: removed
2. all DSM 5 sexual dysfunctions (except w/substance/medications) now require a duration minimum of 6 months and more precise severity criteria.
   
   1. distinguish between transient sexual difficulties and more persisitent sexual dysfunctions.
3. Genito-Pelvic Pain/Penetration Disorder: new merging of Vaginismus and Dyspareunia
   
   1. vaginismus: involuntary spasms of the perineal muscles of vagina, interferes with cock
   2. dyspareunia: genital pain associated with intercourse, men or women.
4. two subtypes for all sexual disorders:
   
   1. lifelong versus acquired
   2. generalized versus situational
      
      1. due to medical and psychological factors has been removed.
5. ​associated features include: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.

Question 2

sexual dysfunction types

Answer 2

1. male erectile dx (impotence) : inability to attain or maintain an adequate erection.
   
   1. physical factors include diabetes mellitus, liver/kidney disease, multiple sclerosis and antipsychotic, antidepressant, and hypertensive drugs.
2. Female/Male Orgasmic Dx: delay in or absence of orgasm
3. Premature Ejaculation: linked to low serotonin levels and may be treated with SSRI (dapoxetine).
4. female sexual interest/arousal disorder
5. Genito-Pelvic Pain/Penetration disorder: replaces dyspareunia and vaginismus

treatment:

• medical evaluation to rule out physiological factors
• ED: complete absence of erections during REM sleep suggests organic etiology.
• if psychogenic factors:
  
  • CBT (via Masters/Johnson) to target dysfunctional behaviors related to anxiety, faulty attitudes and beliefs, lack of knowledge/skills.
  • treatment may involve a couple rather than individual and co-therapists.
• Sex Therapy:
  
  • most helpful for premature ejaculation and Vaginismus
  • sensate focus to reduce performance anxiety; graded exercises that build from nongenital pleasuring to genital stimulation with a ban on orgasm/intercourse
  • start-stop and squeeze techniques and Kegel exercises for premature ejaculation
  • Sildenafil citrate (viagra): increases the ability to maintain an erection, not increase desire for sex.

Question 3

GENDER DYSPHORIA

Answer 3

Gender Dysphoria will have its own chapter in DSM-5 and will be separated from Sexual Dysfunctions and Paraphilic Disorders.

DSM-5

1. people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria.
2. DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder.
3. The critical element of gender dys- phoria is the presence of clinically significant distress associated with the condition.

Characteristics of the Condition

1. must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months.
2. In children, the desire to be of the other gender must be present and verbalized. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. Gender dysphoria is manifested in a variety of ways, including strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reactions typical of the other gender.

The DSM-5 diagnosis adds a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change). This ensures treatment access for individuals who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition.

Part of removing stigma is about choosing the right words. Replacing “disorder” with “dysphoria” in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is “disordered.”

Ultimately, the changes regarding gender dysphoria in DSM-5 respect the individuals identified by offering a diagnostic name that is more appropriate to the symptoms and behaviors they experience without jeopardizing their access to effective treatment options.

Specifier

1. Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).

Question 4

gender dysphoria defined

Answer 4

1. In children, the disturbance is manifested by six (or more) of the following for at least a 6-month duration:
2. repeatedly stated desire to be, or insistence that he or she is, the other sex
3. in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
4. strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
5. a strong rejection of typical toys/games typically played by one’s sex.
6. intense desire to participate in the stereotypical games and pastimes of the other sex
7. strong preference for playmates of the other sex
8. a strong dislike of one’s sexual anatomy
9. a strong desire for the primary (e.g., penis, vagina) or secondary (e.g., menstruation) sex characteristics of the other gender
10. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
11. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
12. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.
13. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
14. The disturbance is not concurrent with a physical intersex condition.
15. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 5

PARAPHILIC DISORDERS

Answer 5

paraphilic disorders are often misunderstood as a catch-all definition for any unusual sexual behavior.

DSM-5, the Sexual and Gender Identity Disorders Work Group sought to draw a line between atypical human behavior and behavior that causes mental distress to a person or makes the person a serious threat to the psychological and physical well-being of other individuals.

Characteristics of Paraphilic Disorders (independent catagory)

Most people with atypical sexual interests do not have a mental disorder. To be diagnosed with a paraphilic disorder, DSM-5 requires that people with these interests:

1. feel personal distress about their interest, not merely distress resulting from society’s disapproval; OR
2. have a sexual desire or behavior that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent.

To further define the line between an atypical sexual interest and disorder, the Work Group revised the names of these disorders to differentiate between the behavior itself and the disorder stemming from that behavior (i.e., Sexual Masochism in DSM-IV will be titled Sexual Masochism Disorder in DSM-5).

It is a subtle but crucial difference that makes it possible for an individual to engage in consensual atypical sexual behavior without inappropriately being labeled with a mental disorder. With this revision, DSM-5 clearly distinguishes between atypical sexual interests and mental disorders involving these desires or behaviors.

The chapter on paraphilic disorders includes eight conditions:

1. exhibitionistic disorder, 2. fetishistic disorder, 3. frotteuristic disorder, 4. pedophilic disorder,
2. sexual masochism disorder, 6. sexual sadism disorder, 7. transvestic disorder, and 8. voyeuristic disorder.

Additional Changes to Paraphilic Disorders

The first concerns transvestic disorder, which identifies people who are sexually aroused by dressing as the opposite sex but who experience significant distress or impairment in their lives—socially or occupationally—because of their behavior. DSM-IV limited this behavior to heterosexual males; DSM-5 has no such restriction, opening the diagnosis to women or gay men who have this sexual interest. While

the change could increase the number of people diagnosed with transvestic disorder, the requirement remains that individuals must experience significant distress or impairment because of their behavior.

Transvestic Disorder Symptoms
Over a period of at least 6 months, in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (for all).
Sexual Masochism & Sadism Disorder Symptoms
Sexual Masochism: Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer.
Pedophilic Disorder Symptoms
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).
Frotteurism Symptoms
Renamed (Frotteuristic Disorder) in DSM-5 Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person.
Fetishistic Disorder Symptoms
The paraphiliac focus in Fetishistic Disorder (formerly known as Fetishism) involves the eroticization of nonliving objects and/or body parts for sexual gratification. Among the more common non-living fetish objects are women’s underpants, bras, stockings, shoes, boots, or other
Exhibitionism (Exhibitionistic) Symptoms
Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the exposure of one’s genitals to an unsuspecting stranger.