Week 6 Lecture 6 - Sexual Dysfunctions, Paraphilias, & Gender Dysphoria - Jo Fielding (DN) Flashcards
Lecture Summary
- Dysfunctions of sexual interest, desire, & arousal
- Aetiology: psychosocial, biological, drug related
- Problems of non-typical focus of sexual desire, arousal & gratification (Paraphilias)
- Aetiology of paraphilias: psychosocial, perhaps some biological causes in some disorders
- Distress accompanying gender identity - Gender dysphoria
What are the three main DSM-5 categories for Sexual Dysfunction?
Disorders of
- Interest, Desire & Arousal
- Orgasm
- Pain
13:20
What are the 3 disorders of Interest, Desire & Arousal?
Males
- Male hypoactive sexual desire disorder
- Erectile disorder
Females
- Female sexual interest/arousal disorder
What are the 3 Orgasmic Disorders?
Males
- Delayed ejaculation
- Premature (early) ejaculation
Females
- Female orgasmic disorder
What is the sexual disorder of Pain?
what gender does it occur in?
Genito-pelvic pain/penetration disorder
occurs in females
Key features of Female Orgasmic Disorder
- Persistent delay, infrequency or absence of orgasm after sexual excitement or
- reduced intensity 6 months or more
- 75% of occasions
Key features of Premature (early) ejaculation
one of the orgasmic disorders
- Persistent, recurrent ejaculation within 1 minute of penetration
- most common reason for referral to sexual clinic
- more common in men with anxiety disorders
- Mild - 30-60 sec
- Moderate - 15-30 sec
- Severe - within 15 sec 6 months +
29:15
How do we define premature?
ejaculating within
- 8 min (people generally complain)
- 3 min (no complaints!!!)
Key features of Delayed Ejaculation?
Persistent delay, infrequency or absence or orgasm
75% of occasions
31:45
What are the key features of Genitopelvic pain/penetration disorder?
Persistent pain with
- intercourse, penetration
- fear or anxiety about pain
- tensing of pelvic floor muscles
33:00
What are the DSM specifiers used to designate the onset of Sexual Dysfunction?
Lifelong
present from first sexual experience
Acquired
develop after period of relatively normal sexual function
Generalised
not limited to certain types of stimulation, situation, partner
Situational
only with certain types of stimulation, situation, partner
16:40
What 5 other factors should be considered during assessment for Sexual Dysfunction?
Factors considered during assessment:
1. Partner factors
- partners’ sexual problems, health status
2. Relationship factors
- poor communication, discrepancies in desire
3. Individual vulnerability factors
- body image, history of abuse, psychiatric comorbidity, stressors
4. Cultural/religious factors
- prohibitions, attitudes towards sexuality
5. Medical factors
- e.g. pelvic nerve damage 17:50
Which DSM-5 criteria exist for ALL of the sexual dysfunctions?
Common diagnostic criteria:
- Symptoms must have persisted for a minimum duration of 6 months
- Symptoms must cause clinically significant distress
- Symptoms not better explained by :
* 1. Non-sexual mental disorder
* 2. Severe relationship distress, partner violence
* 3. Other significant stressor
* 4. Effects of substance/medication
* 5. Other medical condition
- Symptoms not better explained by :
19:25
Female Sexual Interest /Arousal Disorder
A dysfunction of sexual interest, desire & arousal
Diminished, absent, or reduced frequency of at least 3 of the following :
- Interest in sexual activity
- Sexual/erotic thoughts or fantasies
- Initiation of sexual activity & responsiveness to partner’s attempts to initiate
* Beliefs & preferences highly relevant
- Initiation of sexual activity & responsiveness to partner’s attempts to initiate
- Sexual excitement/pleasure - ≥75% of sexual encounters
- Sexual interest/arousal elicited by any internal or external erotic cues
* Adequacy of sexual stimuli?
- Sexual interest/arousal elicited by any internal or external erotic cues
- Genital or nongenital sensations - ≥75% of sexual encounters
22:00
Male Hypoactive Sexual Desire Disorder
A dysfunction of sexual interest, desire & arousal
- Persistently deficient or absent sexual fantasies & desires, as judged by the clinician
- Considerations
- age, general/socio-cultural contexts
- e.g. pregnancies, considering terminating relationship
- Comorbidities
- depression
- other mental disorders
Erectile Disorder
A dysfunction of sexual interest, desire & arousal
- On at least 75% of sexual occasions
- Inability to attain or maintain an erection for completion of sexual activity, or
- Marked decrease in erectile rigidity interferes with penetration or pleasure
- Comorbidities = other sexual diagnoses
Female Orgasmic Disorder
An Orgasmic Disorder
- On at least 75% of sexual occasions;
- Marked delay, infrequency, or absence of orgasm, or
- Markedly reduced intensity of orgasmic sensation
- Inability to achieve orgasm despite adequate sexual desire & arousal
- Most common problem for which females seek professional help
- Threshold for reaching orgasm varies enormously
- ~25% significant difficulty reaching orgasm
- But only ~20% reliably experience orgasm during sex
Equally present in all age groups
- unmarried >married Distinct from sexual arousal
Premature (early) Ejaculation
An Orgasmic Disorder
- Persistent or recurrent pattern of ejaculation
- during partnered sexual activity
- within ~ 1 minute following penetration
- Most common reason for male’s referral to sexuality clinics
- ~60% as presenting complaint
- many also present with erectile dysfunction
- Prevalence: 20-30% at some time
- Promotes considerable anxiety
- Most common in young, sexually inexperienced males
29:15
Delayed Ejaculation
An Orgasmic Disorder
- Marked delay, infrequency, or absence of orgasm
- on at least 75% of sexual occasions
- Seldom seek treatment
- Rarely reported
- 75% report always ejaculating during sex
- Over 50 – loss of peripheral sensory nerves/ lower steroid secretion
Not in DSM-5, but Jo included it
- Retrograde ejaculation
- ejaculatory fluids travel backwards into the bladder rather than forwards
- Almost always caused by drugs or medical condition
31:45
Genitopelvic pain/penetration disorder
The Sexual Pain Disorder
Persistent or recurrent difficulties with at least one of the following:
- Vaginal intercourse/penetration
- Marked vulvovaginal or pelvic pain during vaginal penetration or intercourse attempts
- Marked fear or anxiety about pain or penetration
- Marked tensing of the pelvic floor muscles during attempted vaginal penetration
- Commonly associated with relationship distress
- High prevalence of other disorders related to pelvic floor
- E.g. cystitis, infection, IBS, endometriosis
34:00
What defines Genitopelvic pain/penetration disorder
persistent or recurrent pain during intercourse
pain at entry, during, or after penetration
Describe the process of diagnosis for Genitopelvic pain/penetration disorder
First step in diagnosis, exclude:
- exclude a medical problem (e.g. infection)
- lack of lubrication (common post-menopause)
- Can be diagnosed in men, but rare
- Most women with this disorder experience arousal & can achieve orgasm
Prevalence rates for occasional symptoms
10 – 30% (very common)
Substance/medication-induced sexual dysfunction
RELATES TO ALL OF THE DISORDERS as you can have elements of each without being diagnosable under the other categories.
A clinically significant disturbance in sexual function is predominant in the clinical picture
- Evidence from history, physical examination, lab findings:
- Symptoms developed during or soon after intoxication or withdrawal
- The involved substance is capable of producing the symptoms
- Disturbance does not occur exclusively during the course of a delirium
- Disturbance causes clinically significant distress
Specify with: onset during intoxication or withdrawal, after medication use
Can occur in association with intoxication with following:
- Alcohol, opioids, sedatives, hypnotics or anxiolytics, stimulants (including cocaine)
- Antidepressants, antipsychotics, hormonal contraceptives
Other specified/unspecified sexual dysfunction
If don’t meet the criteria for other disorders, but level of distress warrants intervention
Other specified sexual dysfunction
- Significant distress but symptoms do not meet full criteria
- Significant distress but specific reason doesn’t meet criteria
- e.g. sexual aversion
Unspecified sexual dysfunction
- As above - But typically insufficient information to make specific diagnosis
35: 50
Biological Factors contributing to the aetiology of sexual symptoms?
- **Organic problems **
- Neurological
- (e.g. MS), diabetes, kidney disorders, vascular disease
-
Prescription medication
- Antihypertensives, anxiolytics, antidepressants, tranquillisers
-
Illicit drugs
- Marijuana, opiates (heroin), cocaine
-
Alcohol
- “It provokes the desire, but it takes away the performance”: Macbeth, II, iii, 29
What is extremely important before making a psychological diagnosis of a sexual disorder?
rule out any biological (medical) condition which may be causing the sexual symptoms
What contributing factors are considered in the aetiology of sexual dysfunction?
Psychological Social & Cultural
39:30
Psychological factors contributing to sexual dysfunction?
- Negative expectancies
- Attentional focus on not performing
- Increased autonomic arousal
- Dysfunctional performance
- Avoidance behaviours
39:30
Social and cultural factors contributing to sexual dysfunction?
-
Cultural & religious influences most common cause
- script theory - sex is shameful, dirty
-
Significant negative or traumatic event
- rape, incest, traumatic experiences in initial sexual exposure
- Marked deterioration in close interpersonal relationships
- Sexual inexperience
-
Interaction of psychological & physical factors
- Socially transmitted negative attitudes interact with relationship issues & predispositions to develop performance anxiety
What are treatment approaches for sexual dysfunction
Basic education about sexual functioning
Altering deep-seated myths
Increasing communication between partners
Eliminating psychologically based performance anxiety
- slight variations depending on disorder
Medications & physical treatments:
- Antidepressants:
- where depression contributes to reduced sex drive?
- early ejaculation – e.g. Priligy (short acting SSRI) – under review
- Phosphodiesterase type 5 inhibitor
- (e.g.viagra) for erectile disorder
- Relax smooth muscles – allow blood flow to the penis
- Injection of vasoactive substances into the penis
- Surgery - prosthesis
What is Paraphilia?
Defined by intense, persistent & recurrent sexual attraction to unusual objects or sexual activities
Lasting at least 6 months
Diagnosed only when they cause marked distress or impairment (social, occupational or other important area of functioning), or engages non- consenting others
Disproportionately men, rare in women
- Prevalence? Underestimated, especially criminal acts
May cause untold suffering for self & sometimes others
Common to exhibit comorbid mood, anxiety & substance abuse disorders
What are the 8 DSM-5 Paraphilias?
- Fetishistic disorder
- Transvestic disorder
- Voyeuristic disorder
- Exhibitionistic disorder
- Frotteuristic disorder
- Pedophilic disorder
- Sexual sadism disorder
- Sexual masochism disorder
What is the source of arousal for Fetishistic disorder?
- An inanimate object or
- non-genital body part or
- source of specific tactile stimulation
- involuntary, irresistable
What is the source of arousal for Transvestic disorder?
Cross-dressing
What is the source of arousal for Voyeuristic disorder?
Watching unsuspecting others undress or have sex
What is the source of arousal for Exhibitionistic disorder?
Exposing genitals to an unwilling stranger
What is the source of arousal for Frotteuristic disorder?
Sexual touching or rubbing of an unconsenting person
What is the source of arousal for Pedophilic disorder?
Prepubescent children
What is the source of arousal for Sexual sadism disorder?
Inflicting pain
Fantasies, urges, or behaviours physical or psychological suffering of another
What is the source of arousal for Sexual masochism disorder
Receiving pain
fantasies, urges, or behaviours of being humiliated, beaten, bound, or made to suffer
What are some cognitive distortions often held by Pedophiles?
Misattributing blame
“she started by being too cuddly”
Denying sexual intent
“I was just teaching her about sex ….better from her father than from someone else.”
Debasing the victim
“She’d had sex before with her boyfriend.”
Minimising consequences
“She has always been friendly to me, even afterwards.”
Deflecting censure
“This happened years ago. Why can’t everyone forget about it?”
Justifying the cause
“If I hadn’t been molested as a kid, I’d never have done this.”
What are some facts about Sexual sadism & masochism disorders?
- Relatively acceptable
- debate about inclusion in DSM
- Manifestations of sexual masochism varied
- Both begin in early childhood
- ~20-30% female
- Most lead otherwise conventional lives
Most sadomasochistic behaviours mild & harmless - can become dangerous
Extreme example is sadistic rape
- NOT classified as a paraphilia - most better characterised as assault - some rapists’ crimes do involve paraphilic behaviours - e.g. obsessive rumination on sadistic fantasies
Are Sadomasochistic behaviours dangerous?
- Most sadomasochistic behaviours mild & harmless
- Although can become dangerous
- Extreme example is sadistic rape
- NOT classified as a paraphilia - most better characterised as assault
- some rapists’ crimes do involve paraphilic behaviours
- e.g. obsessive rumination on sadistic fantasies
What does the profile of a person displaying
Sadomasochistic behaviours look like?
No single profile
- hostility towards women
- high incidence of sexual dysfunction, including during rape
- more prevalent in cultures that condone interpersonal violence
Motivation & aetiology of behaviour difficult to determine
What are the Biological factors considered in the Aetiology of Paraphilias?
Excess levels of male hormones?
Temporal lobes change?
What are the Psychological factors considered in the Aetiology of Paraphilias?
- Disordered relationships during childhood / adolescence
- Physical or sexual abuse
- Operant-conditioning
- OCD > similar paradoxical increase in frequency & intensity
- Cognitive distortions / unwarranted beliefs
What are the two common treatment for paraphilias?
Cognitive behavioural therapy
Biological treatments
What is the focus for treatment of paraphilias?
-
Focus on engaging client…..
- often difficult to do
- Lack of motivation to do so
- coz they most likely enjoy their disorder
- it brings them pleasure/arousal
What Cognitive behavioural approaches are used in the treatment of paraphilias?
-
Aversion therapy
- associate negative feelings with inappropriate behaviour or object
- Challenge distorted beliefs about consequences of behaviour
-
Improve
- social skills
- impulse control
- increase empathy
- Identify high risk situations for re-emergence of symptoms
What Biological approaches are used in the treatment of paraphilias?
-
Castration prior to hormonal treatments
- 3% reoffended up to 11 years
-
Medications:
- Particularly among sex offenders
- Typically used to supplement psychological treatment
- Hormonal agents to reduce androgens:
- Medroxyprogesterone acetate (Depo-Provera)
- Cyproterone acetate (Gryostat)
- Luteinizing hormone-releasing hormone agents
- Side effects = infertility, liver problems, diabetes etc
-
Antidepressants
- SSRIs most common
- Poor quality research
- SSRIs most common
- Chemical castration
Gender dysphoria
Marked incongruence between one’s experienced/expressed gender and assigned gender
In children:
- Desire to be or insistence that he or she is, the opposite gender
- Preference for wearing opposite gender clothes
- Preference for cross-gender roles in play or fantasy play
- Preference for playmates of the opposite gender
- Rejection of toys, games, activities associated with assigned gender
- Dislike of one’s sexual anatomy
- Desire for primary and secondary / characteristics that match experienced gender
In adolescents/adults
- As above – desire to be rid of sex characteristics
- Desire to be treated as other gender…. conviction of having feelings/reactions of same
Summarise Gender dysphoria
- Physical gender inconsistent with sense of identity
- Differs from transvestism & hermaphrodism
- No physical abnormalities Independent of sexual arousal patterns
- Rare: in Australia
- 1/24,000 males
- 1/150,000 females
- Controversial status as a disorder
- Natural diversity?
What factors have been considered in the aetiology of gender dysphoria?
Genetic/neurobiological factors
Psychosocial factors
Summarise the two gender reassignment cases discussed in the lecture?
Case 1: Bruce/Brenda (John/Joan in text book) - David Reimer
- twin boy (Bruce) born male, castrated during circumcision
- Returned to male identity 
- Gender reassignment at age 17 months 
- Gender dysphoria in childhood 
- Feminising hormonal therapy from age 12 
- Gender reassignment revealed age 14 
- Sexual attraction - female Sexual behaviour - female (heterosexual)
- Failed to differentiate a female gender identity
Case 2:(Bradley et al) 
- Born as boy, penis ablated during circumcision
- Maintained female identity
- Gender reassignment at age 2 months 
- No gender dysphoria in childhood 
- Feminising hormonal therapy from age 10y,10m
- Gender reassignment revealed age 12
- Sexual attraction - female Sexual behaviour - female & male (bisexual)
- Successfully differentiated a female gender identity
What do the two cases of Gender reassignment suggest about the nature of sexual identity & orientation?
speaks to continuum of sexual identity & orientation
two boys - same procedures at similar times, contrasting outcomes
Case 1
- perceived as a success - reported by psychologist
- although she never felt comfortable as a girl
- despite gender reassignment, hormone therapy & socialisation as a female
- evidence for a biological aetiology
Case 2
- no feelings of uncertainty of being a female
- although had vaginal plasty so she could engage in sexual
- provides evidence for a social/environmental aetiology for gender identity
Genetic/neurobiological factors in aetiology of gender dysphoria?
- Longer CAG repeats on androgen receptor gene for male-to-female GD
- CYP17 gene linked to female-to-male GD
- Size of bed nucleus of the stria terminalis consistent with ‘identified’ gender
- Support from twin studies
- ~ 62% genetic contribution
Psychosocial factors in aetiology of gender dysphoria?
Reinforcement of X-gender behaviour received little support
