Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders

Question 1

Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders

Answer 1

Sexual Dysfunctions: The DSM-5 describes the disorders in this category as involving “a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure” (p. 423). Before a diagnosis of a sexual dysfunction is assigned, it must be determined that the person’s symptoms are not due to a nonsexual mental disorder, a serious relationship disturbance or other stressor, or the effects of a drug or medical condition. For all but one diagnosis, specifiers are provided to indicate the disorder’s onset (lifelong or acquired), extent (generalized or situational) and severity (mild, moderate, or severe). The exception is genito-pelvic pain/penetration disorder, which has specifiers only for onset and severity.

1. Erectile Disorder: For this diagnosis, the person must have at least one of three symptoms on 75 to 100% of all occasions of sexual activity: marked difficulty obtaining an erection during sexual activity, marked difficulty maintaining an erection until completion of sexual activity, marked decrease in erectile rigidity. Symptoms must have been present for at least six months and cause significant distress. An organic etiology can be ruled out if the person has spontaneous erections when not planning to engage in sexual activity, has morning erections, or has erections when masturbating or when with a sexual partner other than his usual partner (Sadock & Sadock, 2008).

Erectile disorder is treated with behavioral techniques and pharmacotherapy. Behavioral techniques focus on reducing performance anxiety and increasing sexual stimulation. For example, sensate focus was developed by Masters and Johnson (1970) as a method for reducing performance anxiety and is used to treat erectile disorder and other sexual dysfunctions. It consists of a series of activities for a couple that are designed to promote intimacy and reduce performance anxiety by having partners focus on pleasurable sensations associated first with non-sexual touching, then with sexual touching, and finally with sexual intercourse. Drugs used to treat erectile disorder include sildenafil citrate (Viagra), tadalafil (Cialis), and vardenafil (Levitra), which increase blood flow to the penis.

2. Premature (Early) Ejaculation: This disorder involves a persistent or recurrent pattern of ejaculation during partnered sexual activity within approximately one minute of vaginal penetration and before the person desires it. Symptoms must have been present for six months or more, occur during 75 to 100% of all occasions of sexual activity, and cause significant distress.

Treatment for premature ejaculation ordinarily includes sensate focus which, as noted above, is used to reduce performance anxiety, and the start-stop technique or pause-squeeze technique, which are used to help men learn to control ejaculation. There’s evidence that a low level of serotonin contributes to this disorder, and research has confirmed that an SSRI taken daily (especially paroxetine) can delay ejaculation for some men (Waldinger & Olivier, 2004).

3. Genito-Pelvic Pain/Penetration Disorder: This disorder involves persistent or recurrent problems with at least one of the following: vaginal penetration during intercourse; marked vulvovaginal or pelvic pain during intercourse or penetration attempts; marked anxiety about vulvovaginal or pelvic pain before, during, or as the result of vaginal penetration; marked tensing of pelvic floor muscles during attempted vaginal penetration. For the diagnosis, symptoms must have a duration of six months or longer and cause significant distress. This disorder has been linked to a history of sexual and/or physical abuse and, for some women, has an onset after a history of vaginal infections. Interventions include relaxation training, sensate focus, a topical anesthetic, vaginal dilators, and Kegel exercises (which are useful for gaining control over pelvic floor muscles).

Gender Dysphoria: This disorder involves a marked incongruence between one’s assigned gender and one’s experienced or expressed gender. For children with this disorder, the diagnosis requires at least six of eight symptoms that last for at least six months and cause significant distress or impaired functioning: e.g., a strong desire to be the other gender, a strong preference for wearing clothes of the other gender, a strong preference for toys and activities typically used or engaged in by the other gender, a strong preference for playmates of the opposite gender; a strong desire for primary and/or secondary sex characteristics of one’s experienced gender. A specifier is used to indicate if the child has a congenital adrenogenital disorder or other disorder of sex development. For adolescents and adults, the diagnosis requires at least two of six symptoms that last for at least six months and cause significant distress or impaired functioning: e.g., a strong desire to be rid of one’s primary and/or secondary sex characteristics; a strong desire to be of the opposite gender; a strong desire to be treated as the opposite gender; a strong conviction that one has the feelings and reactions that are characteristic of the opposite gender. Specifiers are used to indicate if the individual has a disorder of sex development or is in post-transition.

The Dutch protocol and the gender-affirmative model are two approaches to the treatment of gender dysphoria (or, more generally, to the care of gender diverse youth). The Dutch protocol is based on the assumption “that gender dysphoria, or a transgender identity, persists into adolescence in only a small minority of people” (Ehrensaft, Giammattei, Tishelman, & Keo-Meier, 2018, p. 9). Consequently, for children under 12 years of age, it recommends “watchful waiting” accompanied by support for children and their families. Then, at the first signs of puberty, social transition and puberty-blocking drugs are started for children who are persistent in their gender dysphoria. This gives children time to further explore their gender identity and decide if they want to start cross-sex hormone therapy when they’re 16 years of age and undergo gender-affirming surgeries after they’re 18 (de Vries & Cohen-Kettenis, 2012). The gender-affirmative model has become the most widely accepted approach and is based on the assumption that “a child of any age may be cognizant of their authentic identity and will benefit from a social transition at any stage of development” (Ehrensaft, 2017, p. 60). Social transition is followed, as appropriate, by puberty blockers, cross-sex hormones, and surgeries; and, throughout the transition process, gender issues are addressed with youth and their families in a supportive and non-judgmental way. This model also assumes that (a) gender variations are not disorders; (b) gender presentations are diverse and vary across cultures; (c) gender is not always binary and may be fluid; and (d) if present, a child’s psychological problems are often secondary to negative interpersonal and cultural reactions to the child (e.g., transphobia, homophobia, sexism).

Research on the outcomes of gender confirmation surgery (also known as gender-affirming surgery) has generally found that it’s associated with a decrease in gender dysphoria, improved self-satisfaction, and a low incidence of regret. There’s also evidence that transgender male patients have somewhat more positive outcomes than transgender female patients do (Lawrence, 2017). Factors that have been linked to positive outcomes include careful diagnostic screening of individuals seeking surgery, psychological stability, adequate social support, and a lack of surgical complications (Lawrence & Zucker, 2014).

Paraphilic Disorders: The DSM-5 defines a paraphilia as involving “intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners” and a paraphilic disorder as a paraphilia that “is currently causing distress or impairment to the individual or … has entailed personal harm, or risk of harm, to others” (pp. 685-686).

Treatments for paraphilic disorders combine cognitive-behavior therapy with other interventions including group therapy, marital therapy, and/or pharmacotherapy. Cognitive strategies include cognitive restructuring and empathy and skills training. Behavioral strategies are based on classical conditioning and include covert sensitization and orgasmic (masturbatory) reconditioning. Covert sensitization is a form of aversive counterconditioning that’s conducted in imagination and replaces the sexual arousal elicited by the paraphilic object or behavior with fear or other undesirable response. Orgasmic reconditioning involves instructing the person to switch while masturbating from fantasizing about the paraphilic object or behavior to fantasizing about a more appropriate object or behavior. Drugs used to treat severe forms of this disorder include gonadotropin-releasing hormones (e.g., Lupron) and antiandrogens (e.g., Depo-Provera). Although these drugs reduce sexual desire, they have serious side effects and a high risk for relapse as soon as they’re discontinued. SSRIs may be prescribed for individuals with less serious disorders to reduce the depression or compulsions that trigger paraphilic behavior (Kearney & Trull, 2015).

1. Frotteuristic Disorder: This disorder involves recurrent and intense sexual arousal for at least six months from touching or rubbing against a nonconsenting adult as manifested in fantasies, urges, and/or behaviors. For the diagnosis, the person must have acted on the urges with a nonconsenting person or experienced significant distress or impaired functioning as the result of the fantasies or urges.
2. Transvestic Disorder: Transvestic disorder involves cross-dressing for the purpose of sexual arousal for at least six months as manifested in fantasies, urges, and/or behaviors that cause significant distress or impaired functioning. Most men with this disorder identify themselves as heterosexual but may have had occasional sexual relations with men, especially when cross-dressed.
3. Pedophilic Disorder: This disorder involves recurrent and intense sexual arousal for at least six months related to fantasies, urges, and/or behaviors involving sexual activity with a child or children 13 years of age or younger. The person must have acted on these urges or must have experienced significant distress or interpersonal problems because of them and must be 16 years of age or older and at least five years older than the child or children.
4. Fetishistic Disorder: This disorder involves recurrent and intense sexual arousal for at least six months in response to a nonliving object or specific non-genital body part with the arousal causing significant distress or impaired functioning.
5. Exhibitionistic Disorder: Exhibitionistic disorder involves recurrent and intense sexual arousal for at least six months from exposing one’s genitals to an unsuspecting person as manifested by fantasies, urges, or behaviors. For the diagnosis, the person must have acted on the urges with an unsuspecting person or experienced significant distress or impaired functioning as a result of sexual urges or fantasies. There are three subtypes: sexually aroused by exposing genitals to prepubertal children, to physically mature individuals, or to both prepubertal children and physically mature individuals. The diagnosis can be applied to individuals who either disclose information about their exhibitionistic fantasies, urges, or behaviors or deny them despite objective evidence to the contrary.