Week 6 Chapter 12 Sexual Disorders CF

Question 1

When does normal sexual activity & fantasy become regarded as “Abnormal”?

Answer 1

When our fantasies and desire begin to affect us or others in unwanted or harmful ways.

Question 2

What are important aspects influencing what constitutes “normal” sexual activity?

Answer 2

• Definitions of what is normal in sexual behaviour change over time & between culture
• Technology changed how porn & dating can be accessed
• HIV & AIDS changed risks associated with sexual behaviour
• Generational changes, such as baby-boomers, emphasis the right to a good life, which includes sex right up until death

Question 3

What are important issues to consider when considering what constitutes “normal” sexual activity?

Answer 3

It is important to gather samples that are representative of the population in terms of: age, gender ethnicity, sexual orientation, social economic status, & other key variables
Even with sensitivity to participant comfort, it remains difficult to gather data on how common certain behaviours are, as sexuality remains one of the most personal areas of life

Question 4

Name some of the main gender differences in terms of attitude towards sex and sexual satisfaction

Answer 4

• women report thinking about sex, masturbation, & desire for sex, less often than men
• women report less sexual partners compared to men
• women tend to be more ashamed of any flaws in their appearance, than do men; this shame can interfere with sexual satisfaction
• sexuality appears to be more closely tied to relationship status & social norms for women than for men
• Some people recommend a more female-oriented DSM definition of sexual dysfunction: ‘“discontent or dissatisfaction with any emotional, physical, or relational aspect of sexual experience”

Question 5

The DSM has been criticised historically for pathologising homosexuality, despite 15% of males reportedly being same sex attracted. The DSM-5 has attempted to improve this. What is the new category that replaces previous categories of ‘homosexuality’ & ‘sexual orientation disturbance’

Answer 5

The DSM-5 proposes a category of “sexual disorder not otherwise specified” which refers to “persistent & marked distress about one’s sexual orientation”.
This can be applied to a hetrosexual or homosexually oriented person.

Question 6

Gender Dysphoria has been entered in DSM-5 to address issues of ‘Gender Identity’. Why did Kring et al., chose not to include the then proposed ‘Gender Identity Disorder’ in their text book?

Answer 6

• Cross-gender behaviour is universal, even among animal species
• The existence of the diagnosis implicitly contradicts the need for treatments to change the person’s body to suit their gender identity
• Kring et al., did not wish to contribute to further stigmatisation or the social ostracism of people who experience a strong and persistent identification with the opposite sex.

Question 7

Although gender differences are apparent, debate continues about the reasons for these gender differences. What are some of the possibilities?

Answer 7

• They may be based on cultural prohibitions regarding women’s sexuality
• They may be biological, based on women’s greater investment in parenting
• Biology may shape men’s desire for many lifetime partners more than culture does
• Research does suggest some gender differences are remarkably consistent across culture

Question 8

What is the sexual response cycle, as proposed by Kaplan (1974) coming from the studies by Kinsey in the 1940’s & Masters and Johnson in the 1960’s?

Answer 8

1. Desire phase
   sexual interest/desire associated with sexually arousing thoughts or feelings
2. Excitement phase
   increased blood flow to the genitalia; men & women experience pleasure; the penis becomes erect; the vagina becomes lubricated; breasts enlarge
3. Orgasm phase
   sexual pleasure peaks, males ejaculate; for females the outer walls of the vagina contract. for both sexes there is general muscle tension
4. Resolution phase
   a sense of relaxation & well-being. Men have a refractory period where further ejaculation is not possible; women are able to feel sexually excited almost immediately & are able to have multiple orgasms

Question 9

Why does newer data recommend that biological and subjective excitement are considered separately for women, even though they are highly correlated for men?

Answer 9

• Many women experience the desire & excitement phase as one experience
• Desire seems to arise in response to physiological arousal for about 1/3 of women
• Subjective excitement has been found not to correlate with amount of blood flow (using a vaginal plethysmograph

Question 10

Sexuality usually occurs in the context of an intimate personal relationship & can provide a forum for closeness & connection. Given that our sexuality, in part shapes our self-concept, what are impacts on relationships when sexual problems emerge?

Answer 10

Sexual problems can wreak havoc on our self-esteem& relationship
*Partnerships are likely to suffer if sexual dysfunction becomes so severe that the intense satisfaction and tenderness of sexual activity are lost

Question 11

DSM-5 divides sexual dysfunctions into 3 categories. What are they, and what are additional criteria that must be present for a diagnosis to be appropriate?

Answer 11

The 3 categories separate dysfunctions of
*Sexual Desire, Arousal, & Interest
*Orgasmic Disorders
*Sexual Pain Disorders
Separate diagnosis are provided for men and women
*Dysfunction should be persistent & recurrent and should cause clinically significant distress or problems with functioning.

Question 12

What are the DSM-5 diagnosis for sexual dysfunction?

Answer 12

Disorders involving sexual interest, desire & arousal.

• Female Sexual Interest/Arousal Disorder
• Male Hypoactive Sexual Desire DIsorder
• Erectile Disorder

Orgasmic Disorders:

• Female Orgasmic Disorder
• Premature Ejaculation
• Delayed Ejaculation

Sexual Pain Disorders:
*Genito-Pelvic Pain/Penetration Disorder

• Substance/Medication-Induced Sexual Dysfunction
• Other Specified Sexual Dysfunction
• Unspecified Sexual Dysfunction

Question 13

The following 3 disorders:
*Female Sexual Interest/Arousal Disorder
*Male Hypoactive Sexual Desire DIsorder
*Erectile Disorder
are listed in DSM-5 as being related to disorders involving sexual interest, desire & arousal.
How do these manifest & what is the prevalence?

Answer 13

*Female Sexual Interest/Arousal Disorder
*Male Hypoactive Sexual Desire DIsorder
both refer to persistent deficits in sexual interest (fantasies or urges), biological arousal, or subjective arousal

*Erectile Disorder
refers to the failure to attain or maintain an erection through completion of sexual activity

More than 50% of those seeking treatment for sexual dysfunctions complain of low desire, and is more common in men than women.

Question 14

Disorders involving sexual interest, desire & arousal are the most subjective, what are the issues with this area?

Answer 14

• How often should a person desire sex & with what intensity?
• People may have high expectations about being sexual
• Cultural norms seem to influence perceptions of how much sex a person “should” want: Male Hypoactive Sexual Desire DIsorder is reported more often in American than British or German men despite similar levels of sexual activity across these cultures.

Question 15

The following disorders:
*Female Orgasmic Disorder
*Premature Ejaculation
*Delayed Ejaculation
are listed in DSM-5 as being related to Orgasmic Disorders
How do these manifest & what is the prevalence?

Answer 15

*Female Orgasmic Disorder
refers to the persistent absence of orgasm after sexual excitement. This is not diagnosed unless the absence of orgasms is persistent & troubling.
Many females require clitoral stimulation to orgasm, 1/3 of women do not report orgasm during intercourse, 2/3 of women have faked orgasm (largely to protect partners feelings)

*Premature Ejaculation is ejaculating too quickly
20-30% of men report early ejaculation

*Delayed Ejaculation is defined by persistent difficulty in ejaculation
10-20% of men reported trouble reaching ejaculation.

Question 16

Genito-Pelvic Pain/Penetration Disorder listed in DSM-5 as being related to Sexual Pain Disorder
How does this manifest & what is the prevalence?

Answer 16

Genito-Pelvic Pain/Penetration Disorder is defined as persistent and recurrent pain during intercourse. Some women report pain at entry, others only after penetration
It’s important to ensure no medical problem exists, or a lack of vaginal lubrication.

Prevalence rates for occasional symptoms range from 10-30%
It is extremely rare in men.

Question 17

Masters & Johnson (1970) developed a two-tier model of immediate & distal causes to conceptualise the etiology of human sexual inadequacy.
What did they identify as the distal causes of human sexual inadequacy?

Answer 17

The distal causes of human sexual inadequacy are:
*Religious orthodoxy
*Psychosexual trauma
*Homosexual inclination
*Inadequate counselling
*Excessive Alcohol Intake
*Physiological problems
Sociocultural factors

Question 18

Masters & Johnson (1970) developed a two-tier model of immediate & distal causes to conceptualise the etiology of human sexual inadequacy.
What did they identify as the immediate causes of human sexual inadequacy?

Answer 18

The immediate causes of human sexual inadequacy are taking on a spectator role and fears about performance.
spectator role: being an observer rather than a participant in a sexual experience
Fears about performance: concerns with how one is performing during sex
Both involve a focus on sexual performance that impedes the natural sexual responses

Question 19

What are the the psychological, physical, & social and sexual history factors that are thoughts to contribute to successful sexual functioning?

Answer 19

• psychological
• Good emotional health
• Attraction to partner
• Positive attitude towards partner
• Positive sexual attitude
• physical
• Good physical health
• Regular appropriate exercise
• Good Nutrition
• social and sexual history factors
• Positive sexual experiences in past
• Good relationship with partner
• Sexual knowledge or skills

Question 20

What are the the psychological, physical, & social and sexual history factors that are thoughts to contribute to poor sexual functioning?

Answer 20

• psychological
• Depression or Anxiety disorders
• Focus on performance, -Too much routine,
• Poor self esteem, -Uncomfortable environment for sex, -Rigid, narrow attitude toward sex, -Negative thoughts about sex
• physical
• Smoking, -Heavy drinking, -Diabetes
• Cardiovascular problems, -Neurological diseases
• Low physiological arousal, -SSRI meds;
• anti-hypertension meds; -Other drugs
• social and sexual history factors
• Rape or sexual abuse
• Relationship problems (e.g. anger, poor communication)
• Long period of abstinence
• History of hurried sex

Question 21

What was the Masters & Johnson’s Sex therapy program developed to treat Sexual Dysfunction?

Answer 21

*Masters & Johnson’s Sex therapy programs - the couple is encouraged to see the problem as their mutual responsibility, -sensate focus exercises promote contact, a first step towards re-establishing intimacy, -the female then maximises her sexual stimulation, then the woman takes charge of the intercourse

Question 22

What are some of the Anxiety Reduction treatments for Sexual Dysfunction?

Answer 22

• Anxiety reduction
• gradual and systematic exposure to anxiety-provoking aspects of sexual situations,
• including systematic desensitisation & in-vivo (real-life) desensitisation,
• psychoeducational programs.
• anxiety reduction targeted to the specific issue

Question 23

What are some of the other treatments for Sexual Dysfunction?

Answer 23

*Directed masturbation (success rate of 90%)
*Procedures to change Attitude & Thoughts
*Skills & Communication Training
(explicit training films & communication)
*Couples Therapy
*Medications & Physical Treatment - especially useful for Premature Ejaculation anti-depressants can treat premature ejaculation; & Erectile Disorder viagra & Cialis are drugs which treat erectile dysfunction

Question 24

What are Paraphilias?

Answer 24

• Paraphilias are a group of disorders defined by recurrent sexual attraction to unusual objects or sexual activities lasting at least six months.
• There is a deviation in what the person is attracted to.
• DSM differentiates the paraphilias based on the source of arousal

Question 25

What are the names of the Paraphilias, as they appear in the DSM-5?

Answer 25

* Voyeuristic Disorder * Exhibitionistic Disorder * Frotteuristic Disorder * Sexual Masochism Disorder * Sexual Sadism Disorder * Paedophilic Disorder * Fetishistic Disorder * Transvestic Disorder * Other Specified Paraphilic Disorder * Unspecified Paraphilic Disorder

Question 26

What is the main source of controversy surrounding the diagnosis of some of the paraphilias?

Answer 26

* Surveys have shown that many people occasionally fantasise about some of the activities that constitute paraphilies * Some behaviours are becoming more common, so is it appropriate to diagnose them as disorders? * Fetishistic Disorder, *Sexual Masochism Disorder * Sexual Sadism Disorder & *Transvestic Disorder have been removed by the Swedish Board of Health & Welfare * Many people practice variant sexual behaviours safely with consenting adult partners & do not experience distress or impairment as a result

Question 27

How has the DSM-5 responded to the controversy surrounding the diagnosis of some of the paraphilias?

Answer 27

The DSM-5 emphasises these disorders should only be diagnosed when they cause marked distress or impairment, or when a person engages in sexual activities with a non-consenting person

Question 28

Kring et al., are not happy that | Transvestic Disorder continues to be a disorder listed in the DSM. What is their issue with it?

Answer 28

* Transvestic disorder does not typically involve non-consenting others, and it rarely leads to impairment, the diagnosis of the disorder typically rests on the presence of distress. * The person who feels guilty & ashamed because he or she has internalised stigma about this behaviour is diagnosable. * The general feeling from Kring is Transvestic Disorder is a problem of societal stigma, rather than a disorder for an individual

Question 29

Why are statistics on the paraphilias unlikely to be accurate?

Answer 29

* People are unlikely to report as some are illegal e.g. Paedophilic Disorder involves non-consenting children;Frotteuristic Disorder involves rubbing on non-consenting people; Voyeuristic & Exhibitionistic Disorder have potential to be illegal * Even those people who are prosecuted for crimes related to their paraphilic activities are not likely to be charged for voyeurism for example * Other people may feel stigmatised by society if they acknowledge their paraphilic tendencies, so they too, will under-report

Question 30

What is Fetishistic Disorder as defined by the | DSM-5?

Answer 30

Fetishistic Disorder A. Over a period of 6 months, recurrent & intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), 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 (e.g. transvestic disorder) or devices specifically designed for the purposes of tactile genital stimulation (e.g. vibrator)

Question 31

How will the Fetishistic Disorder affect the individual experiencing it?

Answer 31

* The person with the Fetishistic disorder feels a compulsive attraction to objects that is involuntary and irresistible. * It is this intense degree of the erotic focus that distinguishes the fetishist from someone who simply likes high heels * The disorder usually begins in adolescence. * People with fetishistic disorder often have other paraphilias such as Sexual Masochism or Sadism Disorder, or Paedophilic Disorder

Question 32

What is Paedophilic Disorder as defined by the | DSM-5?

Answer 32

Paedophilic Disorder A. Over a period of 6 months, recurrent & intense arousing fantasies, sexual urges or behaviours involving sexual activity with a prepubescent child or children (generally aged 13 or under) B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty C. The individual is at least 16 years of age, & at least 5 years older than the child or children in Criteria A. Note: Do not include an individual in late adolescence involved in an on-going relationship with a 12 or 13 year old Specify whether: Exclusive type (attracted only to children) Non-exclusive type Specify if: Sexually attracted to Males/Female/Both Specify if: Limited to Incest

Question 33

What is Paedophilic Disorder & what does someone with this disorder actually do to children (warning - graphic descriptions)?

Answer 33

* Adults who derive sexual gratification through sexual contact with prepubertal or pubescent children, or when they experience recurrent, intense, & distressing desires for sexual contact with prepubertal or pubescent children. * Most men with Paedophilic Disorder report they use child pornography * A strong subjective attraction impels the behaviour * Sometimes they will just be content to stroke the child's hair, but more often it will involve manipulating the child's genitalia & encouragement for the child to reciprocate * Penile insertion is less often * The molestations may be repeated over weeks, months, years if not discovered * People with Paedophilic Disorder usually molest children they know. * Overt physical force is rarely used (threats of trouble, or to pets, etc are usually used) * Child Sexual Abuse Inherently involves a betrayal of trust & other serious negative consequences

Question 34

Incest is a sub-type of Paedophilic Disorder. What does this entail?

Answer 34

* Incest refers to sexual relations between close relatives for whom marriage is forbidden * It is most common between brother and sister * The next most common form, thought to be more pathological, is between father & daughter

Question 35

What are some of the societal values influencing views on Incest?

Answer 35

* Incest is a virtually universal taboo - Egyptian pharaohs were however able to marry their sisters or other females in their immediate family * The incest taboo makes sense from an evolutionary perspective, children born of incest have a greater probability of inheriting recessive genes (one from each parent) * Families where incest occurs may be unusually patriarchal, especially with respect to the subservient position of women to men. * Parents also tend to be more neglectful & emotionally distant * Men who commit incest abuse their pubescent daughters, whilst paedophiles tend to prefer prepubescent children

Question 36

What are the demographic characteristics of people who commit incest or who have Paedophilic Disorder?

Answer 36

* Most are hetrosexual (though can be gay or straight) * About 50% of child molestations (including those in the family) are by adolescent boys * Academic problems are common * Criminal behaviour is common * Most older hetrosexual men with Paedophilic Disorder have been married * Men with Paedophilic Disorder demonstrate elevated impulsivity & psychopathology compared with the general population * They are often comorbid for conduct disorder & substance abuse * Molestations are more likely to occur when they are intoxicated * Depression & anxiety are common * People with Paedophilic Disorder tend to fantasise when their mood is low, which in turn exacerbates their low mood, potentially contributing to the urge to molest

Question 37

What is Voyeuristic Disorder as defined by the | DSM-5?

Answer 37

Voyeuristic Disorder A. Over a period of 6 months, recurrent & intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, 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 C. The individual experiencing the arousal &/or acting on the urges is at least 18 years of age Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in an institution or other settings where opportunities to engage in voyeuristic behaviour are restricted In Full remission: The Individual has not acted on the urges with a non-consenting person, & there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in a controlled environment

Question 38

What are the demographic characteristics of people who have Voyeuristic Disorder?

Answer 38

* The prevalence is difficult to assess due to underreporting and criminal implications. People are often charged with loitering rather than with Voyeuristic Disorder * Voyeuristic Disorder typically develops in adolescence * People with Voyeuristic Disorder often have other paraphilias, but do not often have other mental disorders

Question 39

What is Frotteuristic Disorder as defined by the | DSM-5?

Answer 39

Frotteuristic Disorder A. Over a period of 6 months, recurrent & 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 C. The individual experiencing the arousal &/or acting on the urges is at least 18 years of age Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in an institution or other settings where opportunities to touch or rub against a non-consenting person are restricted In Full remission: The Individual has not acted on the urges with a non-consenting person, & there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in a controlled environment

Question 40

How does Frotteuristic Disorder manifest?

Answer 40

Frotteuristic Disorder involves the sexually oriented touching of an unsuspecting person. *The frotteur may rub his penis against a woman's thighs or buttocks or fondle her breasts or genitals *These attacks typically occur in crowded places (tubes, buses, crowds) Frotteuristic Disorder typically occurs alongside other paraphilias

Question 41

What is the etiology of the paraphilias?

Answer 41

* Neurobiological Factors: - Most people with a paraphilia are men, so speculation for androgens (hormones like testosterone) play a role - Androgens regulate sexual desire & sexual desire seems to play a large part in the paraphilias - However men with paraphilias do not seem to have high testosterone or other androgens *There is likely to be a complex network of causes. Not much is really known * Psychological Factors: - focus on risk factors with dominant models: -emphasising conditioning experiences, - relationship histories, - abuse: physical &/or sexual - cognition - hostile thinking - Inadequate social skills

Question 42

Give some examples of cognitive distortions in the paraphilias

Answer 42

* blame is misattributed (She started it) * Denying sexual intent (I was teaching her about sex) * Debasing the victim (She was a slut anyway) * Minimising consequences (She was messed up before this happened) * Deflecting censure (it was years ago, forget about it) * Justifying the cause (if my girlfriend gave me what I wanted, I wouldn't have needed to rape her)

Question 43

What are some of the treatments for paraphilias?

Answer 43

- Outcomes are highly variable * Strategies to enhance motivation: - empathise with victim - treatment might help change behaviour - emphasise the negative consequences of their behaviour * Cognitive Behavioural Treatment: - aversion therapy - challenge distorted thinking - social skills training - sexual impulse control - empathy training - relapse prevention * Biological treatments: - chemical or physical castration - hormone treatments to reduce androgens - SSRI antidepressants