Disorders of Sex and Gender

1. Disorders of Sex and Gender Chapter 13 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

2. Disorders of Sex and Gender • Sexual behavior is a major focus of both our private thoughts and public discussions • Experts recognize two general categories of sexual disorders: • Sexual dysfunctions – problems with sexual responses • Paraphilic disorders– repeated and intense sexual urges and fantasies in response to socially inappropriate objects or situations Comer, Abnormal Psychology, DSM-5 Update, 8e

3. Disorders of Sex and Gender • DSM-5 also includes a category called gender dysphoria , a pattern in which people feel that they have been born to the wrong sex Comer, Abnormal Psychology, DSM-5 Update, 8e

4. Disorders of Sex and Gender • Relatively little is known about racial and other cultural differences in sexuality • Sex therapists and sex researchers have only recently begun to attend systematically to the importance of culture and race Comer, Abnormal Psychology, DSM-5 Update, 8e

5. Sexual Dysfunctions • Sexual dysfunctions are disorders in which people cannot respond normally in key areas of sexual functioning • As many as 31% of men and 43% of women in the U.S. suffer from such a dysfunction during their lives • Sexual dysfunctions are typically very distressing, and often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems • Often these dysfunctions are interrelated; many patients with one dysfunction experience another as well Comer, Abnormal Psychology, DSM-5 Update, 8e

6. Sexual Dysfunctions • The human sexual response can be described as a cycle with four phases: • Desire • Excitement • Orgasm • Resolution • Sexual dysfunctions affect one or more of the first three phases Comer, Abnormal Psychology, DSM-5 Update, 8e

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9. Sexual Dysfunctions • Some people struggle with sexual dysfunction their whole lives (labeled “lifelong type”) or others, normal sexual functioning preceded the disorder (labeled “acquired type”) • In some cases the dysfunction is present during all sexual situations (labeled “generalized type”) • In others it is tied to particular situations (labeled “situational type”) Comer, Abnormal Psychology, DSM-5 Update, 8e

10. Disorders of Desire • Desire phase of the sexual response cycle • Consists of an interest in or urge to have sex, sexual fantasies, and sexual attraction to others • Two dysfunctions affect this phase: • Male hypoactive sexual desire disorder • Female sexual interest/arousal disorder Comer, Abnormal Psychology, DSM-5 Update, 8e

11. Disorders of Desire • Male hypoactive sexual desire disorder • Characterized by a lack of interest in sex and little sexual activity • Physical responses may be normal • Prevalent in about 16% of men Comer, Abnormal Psychology, DSM-5 Update, 8e

12. Disorders of Desire • Female sexual interest/arousal disorder • Characterized by a lack of normal interest in sexual activity • Women with this condition rarely initiate sexual activity and may experience little excitement during sexual activity • Reduced sexual interest and desire may be found in as many as 33% of women Comer, Abnormal Psychology, DSM-5 Update, 8e

13. Disorders of Desire • A person’s sex drive is determined by a combination of biological, psychological, and sociocultural factors, and any of these may reduce sexual desire • Most cases of low sexual desire are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly Comer, Abnormal Psychology, DSM-5 Update, 8e

14. Disorders of Desire • Biological causes • A number of hormones interact to produce sexual desire and behavior • Abnormalities in their activity can lower sex drive • These hormones include prolactin, testosterone, and estrogen for both men and women • Recent investigation has also linked sexual desire disorders to excessive activity of the NTs serotonin and dopamine • Sex drive can also be lowered by some medications (including birth control pills and pain medications), some psychotropic drugs, a number of illegal drugs, and chronic illness Comer, Abnormal Psychology, DSM-5 Update, 8e

15. Disorders of Desire • Psychological causes • A general increase in anxiety, depression, or anger may reduce sexual desire in both men and women • Fears, attitudes, and memories may contribute to sexual dysfunction • Certain psychological disorders, including depression and obsessive-compulsive disorder, may lead to sexual desire disorders Comer, Abnormal Psychology, DSM-5 Update, 8e

16. Disorders of Desire • Sociocultural causes • Attitudes, fears, and psychological disorders that contribute to sexual desire disorders occur within a social context • Many sufferers of desire disorders are feeling situational pressures • Examples: divorce, death, job stress, infertility, and/or relationship difficulties • Cultural standards can set the stage for development of these disorders • The trauma of sexual molestation or assault is especially likely to produce sexual dysfunction Comer, Abnormal Psychology, DSM-5 Update, 8e

17. Disorders of Excitement • Excitement phase of the sexual response cycle • Marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing • In men: erection of the penis • In women: swelling of the clitoris and labia and vaginal lubrication • Female sexual interest/arousal disorder may include dysfunction during the excitement phase • In addition, a male disorder – erectile disorder – involves dysfunction in the excitement phase only Comer, Abnormal Psychology, DSM-5 Update, 8e

18. Disorders of Excitement • Erectile disorder (ED) • Characterized by persistent inability to attain or maintain an erection during sexual activity • This problem occurs in as much as 10% of the general male population • According to surveys, half of all adult men have erectile difficulty during intercourse at least some of the time Comer, Abnormal Psychology, DSM-5 Update, 8e

19. Disorders of Excitement • Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes Comer, Abnormal Psychology, DSM-5 Update, 8e

20. Disorders of Excitement • Biological causes • The same hormonal imbalances that can cause male hypoactive sexual desire can also produce ED • Most commonly, vascular problems are involved • ED can also be caused by damage to the nervous system from various diseases, disorders, or injuries • The use of certain medications and various forms of substance abuse may interfere with erections Comer, Abnormal Psychology, DSM-5 Update, 8e

21. Disorders of Excitement • Biological causes • Medical procedures have been developed for diagnosing biological causes of ED • One strategy involves measuring nocturnal penile tumescence (NPT) • Men typically have erections during REM sleep; abnormal or absent nighttime erections usually indicate a physical basis for erectile failure Comer, Abnormal Psychology, DSM-5 Update, 8e

22. Disorders of Excitement • Psychological causes • Any of the psychological causes of male hypoactive sexual desire can also interfere with arousal and lead to erectile dysfunction • For example, as many as 90% of men with severe depression experience some degree of ED Comer, Abnormal Psychology, DSM-5 Update, 8e

23. Disorders of Excitement • Psychological causes • One well-supported cognitive explanation for ED emphasizes performance anxiety and the spectator role • Once a man begins to have erectile difficulties, he becomes fearful and worries during sexual encounters; instead of being a participant, he becomes a spectator and judge • This can create a vicious cycle of sexual dysfunction where the original cause of the erectile failure becomes less important than the fear of failure Comer, Abnormal Psychology, DSM-5 Update, 8e

24. Disorders of Excitement • Sociocultural causes • Each of the sociocultural factors that contribute to male hypoactive sexual desire has also been linked to ED • Job and marital distress are particularly relevant Comer, Abnormal Psychology, DSM-5 Update, 8e

25. Disorders of Orgasm • Orgasm phase of the sexual response cycle • Sexual pleasure peaks and sexual tension is released as the muscles in the pelvic region contract rhythmically • For men: semen is ejaculated • For women: the outer third of the vaginal walls contract • There are three disorders of this phase: • Premature ejaculation • Delayed ejaculation • Female orgasmic disorder Comer, Abnormal Psychology, DSM-5 Update, 8e

26. Disorders of Orgasm • Premature ejaculation • Characterized by persistent reaching of orgasm and ejaculation within one minute of beginning sexual activity with a partner and before he wishes to • As many as 30% of men experience rapid ejaculation at some time • Psychological, particularly behavioral, explanations of this disorder have received more research support than other explanations • The dysfunction seems to be typical of young, sexually inexperienced men • It may also be related to anxiety, hurried masturbation experiences, or poor recognition of arousal Comer, Abnormal Psychology, DSM-5 Update, 8e

27. Disorders of Orgasm • Premature ejaculation • There is a growing belief among many clinical theorists that biological factors may also play a key role in many cases of this disorder • One theory states that some men are born with a genetic predisposition • A second theory argues that the brains of men with early ejaculation contain certain serotonin receptors that are overactive and others that are underactive • A third explanation holds that men with this dysfunction experience greater sensitivity or nerve conduction in the area of their penis Comer, Abnormal Psychology, DSM-5 Update, 8e

28. Disorders of Orgasm • Delayed ejaculation • Characterized by a repeated inability to ejaculate or by a very delayed ejaculation after normal sexual activity with a partner • Occurs in 8% of the male population • Biological causes include low testosterone, neurological disease, and head or spinal cord injury • Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the sympathetic nervous system, can also affect ejaculation Comer, Abnormal Psychology, DSM-5 Update, 8e

29. Disorders of Orgasm • Delayed ejaculation • A leading psychological cause appears to be performance anxiety and the spectator role, the cognitive factors involved in ED • Another psychological factor may be past masturbation habits • This disorder also may develop out of male hypoactive sexual desire disorder Comer, Abnormal Psychology, DSM-5 Update, 8e

30. Disorders of Orgasm • Female orgasmic disorder • Characterized by persistent failure to reach orgasm, experiencing orgasms of very low intensity, or delay in orgasm • Almost 24% of women appear to have this problem • 10% or more have never reached orgasm • An additional 9% reach orgasm only rarely • Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly • Female orgasmic disorder is more common in single women than in married or cohabiting women Comer, Abnormal Psychology, DSM-5 Update, 8e

31. Disorders of Orgasm • Female orgasmic disorder • Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning • Early psychoanalytic theory used to consider lack of orgasm during intercourse to be pathological • Current evidence suggests that this is untrue • Once again, biological, psychological, and sociocultural factors may combine to produce these disorders • Because arousal plays a key role in orgasms, arousal difficulties often are featured in explanations of female orgasmic disorder Comer, Abnormal Psychology, DSM-5 Update, 8e

32. Disorders of Orgasm • Female orgasmic disorder • Biological causes • A variety of physiological conditions can affect a woman’s arousal and orgasm • These conditions include diabetes and multiple sclerosis • The same medications and illegal substances that affect erection in men can affect arousal and orgasm in women • Postmenopausal changes may also be responsible Comer, Abnormal Psychology, DSM-5 Update, 8e

33. Disorders of Orgasm • Female orgasmic disorder • Psychological causes • The psychological causes of female sexual interest/arousal disorder, including depression, may also lead to female arousal and orgasmic disorders • Memories of childhood trauma and relationship distress may also be related Comer, Abnormal Psychology, DSM-5 Update, 8e

34. Disorders of Orgasm • Female orgasmic disorder • Sociocultural causes • For years, the leading sociocultural theory of female orgasmic problems was that it resulted from sexually restrictive cultural messages • This theory has been challenged because: • Sexually restrictive histories are equally common in women with and without disorders • Cultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant Comer, Abnormal Psychology, DSM-5 Update, 8e

35. Disorders of Orgasm • Female orgasmic disorder • Sociocultural causes • Researchers suggest that unusually stressful events, traumas, or relationships may produce the fears, memories, and attitudes that characterize these dysfunctions • Research has also linked orgasmic behavior to certain qualities in a woman’s intimate relationships (such as emotional intimacy) Comer, Abnormal Psychology, DSM-5 Update, 8e

36. Disorders of Sexual Pain • Certain sexual dysfunctions are characterized by enormous physical discomfort during intercourse and do not fit neatly into a specific phase of the sexual response cycle • These dysfunctions, collectively called genito-pelvic pain/penetration disorder, are experienced by women much more often than men Comer, Abnormal Psychology, DSM-5 Update, 8e

37. Disorders of Sexual Pain • Some women with genito-pelvic pain/penetration disorder experience involuntary contractions of the muscles of the outer third of the vagina • Known as vaginismus, severe cases can prevent a woman from having intercourse • This problem has received relatively little research, but estimates are that it occurs in fewer than 1% of all women Comer, Abnormal Psychology, DSM-5 Update, 8e

38. Disorders of Sexual Pain • Most clinicians agree with the cognitive-behavioral theory that this form of genito-pelvic pain/penetration disorder is a learned fear response • A variety of factors can set the stage for this fear, including anxiety and ignorance about intercourse, exaggerated stories, trauma caused by an unskilled partner, and the trauma of childhood sexual abuse or adult rape • Some women experience painful intercourse because of infection or disease Comer, Abnormal Psychology, DSM-5 Update, 8e

39. Disorders of Sexual Pain • Other women with genito-pelvic pain/penetration disorder experience severe vaginal or pelvic pain during sexual intercourse • This pattern is known medically as dyspareunia • As many as 14% of women suffer from this problem • This form of genito-pelvic pain/penetration disorder usually has a physical cause, most commonly from injury sustained in childbirth • Although psychological factors or relationship difficulties may contribute to this problem, psychosocial factors alone are rarely responsible Comer, Abnormal Psychology, DSM-5 Update, 8e

40. Treatments for Sexual Dysfunctions • The last 40 years have brought major changes in the treatment of sexual dysfunction • Early 20th century: psychodynamic therapy • Believed that sexual dysfunction was caused by a failure to progress through the stages of psychosexual development • Therapy focused on gaining insight and making broad personality changes; was generally unhelpful Comer, Abnormal Psychology, DSM-5 Update, 8e

41. Treatments for Sexual Dysfunctions • 1950s and 1960s: behavioral therapy • Behavioral therapists attempted to reduce fear by applying relaxation training and systematic desensitization • Had some success, but failed to work in cases where the key problems included misinformation, negative attitudes, and lack of effective sexual techniques Comer, Abnormal Psychology, DSM-5 Update, 8e

42. Treatments for Sexual Dysfunctions • 1970: Human Sexual Inadequacy • This book, written by William Masters and Virginia Johnson, revolutionized treatment of sexual dysfunctions • This original “sex therapy” program has evolved into a complex approach • Includes techniques from cognitive, behavioral, couples, and family systems therapies, along with a number of sex-specific techniques • More recently, biological interventions have also been incorporated Comer, Abnormal Psychology, DSM-5 Update, 8e

43. What Are the General Features of Sex Therapy? • Modern sex therapy is short-term and instructive • Therapy typically lasts 15 to 20 sessions • It is centered on specific sexual problems rather than on broad personality issues Comer, Abnormal Psychology, DSM-5 Update, 8e

44. What Are the General Features of Sex Therapy? • Modern sex therapy focuses on: • Assessment and conceptualization of the problem • Mutual responsibility • Education about sexuality • Emotion identification • Attitude change • Elimination of performance anxiety and the spectator role • Increasing sexual and general communication skills • Changing destructive lifestyles and marital interactions • Addressing physical and medical factors Comer, Abnormal Psychology, DSM-5 Update, 8e

45. What Techniques Are Applied to Particular Dysfunctions? • In addition to the general components of sex therapy, specific techniques can help in each of the sexual dysfunctions Comer, Abnormal Psychology, DSM-5 Update, 8e

46. What Techniques Are Applied to Particular Dysfunctions? • Disorders of Desire • These disorders are among the most difficult to treat because of the many issues that feed into them • Therapists typically apply a combination of techniques, which may include: • Affectual awareness, self-instruction training, behavioral techniques, insight-oriented exercises, and biological interventions such as hormone treatments Comer, Abnormal Psychology, DSM-5 Update, 8e

47. What Techniques Are Applied to Particular Dysfunctions? • Erectile disorder • Treatments for ED focus on reducing a man’s performance anxiety and/or increasing his stimulation • May include sensate-focus exercises such as the “tease technique” Comer, Abnormal Psychology, DSM-5 Update, 8e

48. What Techniques Are Applied to Particular Dysfunctions? • Erectile disorder • Biological approaches have gained great momentum with the development of sildenafil (Viagra) and other erectile dysfunction drugs • Most other biological approaches have been around for decades and include gels, suppositories, penile injections, and a vacuum erection device (VED) • These procedures are now viewed as “second-line” treatment Comer, Abnormal Psychology, DSM-5 Update, 8e

49. What Techniques Are Applied to Particular Dysfunctions? • Premature ejaculation • Premature ejaculation has been successfully treated for years by behavioral procedures such as the “stop-start” or “pause” procedure • Some clinicians use SSRIs, the serotonin-enhancing antidepressant drugs • Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation • Many studies have reported positive results with this approach Comer, Abnormal Psychology, DSM-5 Update, 8e

50. What Techniques Are Applied to Particular Dysfunctions? • Delayed ejaculation • Therapies for this disorder include techniques to reduce performance anxiety and increase stimulation • When the cause of the disorder is physical, treatment may include a drug to increase arousal of the sympathetic nervous system Comer, Abnormal Psychology, DSM-5 Update, 8e