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Chapter 13. Sexual Disorders and Gender Identity Disorder. Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University. Sexual Disorders and Gender Identity Disorder. Sexual behavior is a major focus of both our private thoughts and public discussions

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chapter 13

Chapter 13

Sexual Disorders and Gender Identity Disorder

Slides & Handouts by Karen Clay Rhines, Ph.D.

Seton Hall University

sexual disorders and gender identity disorder
Sexual Disorders and Gender Identity Disorder
  • 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
    • Paraphilias – sexual urges and fantasies in response to socially inappropriate objects or situations
  • The DSM also includes a diagnosis called gender identity disorder, a sex-related disorder in which people feel that they have been assigned to the wrong sex
sexual dysfunctions
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
sexual dysfunctions4
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
sexual dysfunctions7
Sexual Dysfunctions
  • Some people struggle with sexual dysfunction their whole lives (labeled “lifelong type” in DSM-IV)
    • For 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”)
disorders of desire
Disorders of Desire
  • Desire phase of the sexual response cycle
    • Consists of an urge to have sex, sexual fantasies, and sexual attraction to others
  • Two dysfunctions affect this phase:
    • Hypoactive sexual desire disorder
    • Sexual aversion disorder
disorders of desire9
Disorders of Desire
  • Hypoactive sexual desire disorder
    • Characterized by a lack of interest in sex and a low level of sexual activity
      • Physical responses may be normal
    • Prevalent in about 16% of men and 33% of women
    • DSM refers to “deficient” sexual interest/activity but provides no definition of “deficient”
      • In reality, this criterion is difficult to define
disorders of desire10
Disorders of Desire
  • Sexual aversion disorder
    • Characterized by a total aversion to (disgust of) sex
      • Sexual advances may sicken, repulse, or frighten
    • This disorder seems to be rare in men and more common in women
disorders of desire11
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 or sexual aversion are caused primarily by sociocultural and psychological factors, but biological conditions can also lower sex drive significantly
disorders of desire12
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
    • Sex drive can also be lowered by chronic illness, some medications, some psychotropic drugs, and a number of illegal drugs
disorders of desire13
Disorders of Desire
  • Psychological causes
    • A general increase in anxiety or anger may reduce sexual desire in both women and men
    • Fears, attitudes, and memories may contribute to sexual dysfunction
    • Certain psychological disorders, including depression and obsessive-compulsive disorder, may lead to sexual desire disorders
disorders of desire14
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 impact the development of these disorders
      • The trauma of sexual molestation or assault is also likely to produce sexual dysfunction
disorders of excitement
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: clitoral swelling and vaginal lubrication
  • Two dysfunctions affect this phase:
    • Female sexual arousal disorder (formerly “frigidity”)
    • Male erectile disorder (formerly “impotence”)
disorders of excitement16
Disorders of Excitement
  • Female sexual arousal disorder
    • Characterized by repeated inability to maintain proper lubrication or genital swelling during sexual activity
      • Many with this disorder also have desire or orgasmic disorders
    • It is estimated that more than 10% of women experience this disorder
    • Because this disorder is so often tied to an orgasmic disorder, researchers usually study the two together; causes of the two disorders will be examined together
disorders of excitement17
Disorders of Excitement
  • Male erectile disorder (ED)
    • Characterized by repeated inability to attain or maintain an adequate erection during sexual activity
    • An estimated 10% of men experience this disorder
      • Most are over the age of 50 years
      • Many cases are associated with medical ailments or disease
    • According to surveys, half of all adult men have erectile difficulty during intercourse at least some of the time
disorders of excitement18
Disorders of Excitement
  • Most cases of erectile disorder result from an interaction of biological, psychological, and sociocultural processes
    • Even minor physical impairment of the erection response may make a man vulnerable to the effects of psychosocial factors
disorders of excitement19
Disorders of Excitement
  • Biological causes
    • The same hormonal imbalances that can cause 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 substances may interfere with erections
disorders of excitement20
Disorders of Excitement
  • Biological causes
    • Medical devices 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
disorders of excitement21
Disorders of Excitement
  • Psychological causes
    • Any of the psychological causes of hypoactive sexual desire can also interfere with erectile function
      • For example, as many as 90% of men with severe depression experience some degree of ED
    • 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 worried 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
disorders of excitement22
Disorders of Excitement
  • Sociocultural causes
    • Each of the sociocultural factors tied to hypoactive sexual desire has also been linked to ED
      • Job and marital distress are particularly relevant
disorders of orgasm
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
    • Male orgasmic disorder
    • Female orgasmic disorder
disorders of orgasm24
Disorders of Orgasm
  • Premature ejaculation
    • Characterized by persistent reaching of orgasm and ejaculation with little sexual stimulation
      • About 30% of men experience premature ejaculation at some time
    • Psychological, particularly behavioral, explanations of this disorder have received more research support than other theories
      • 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
disorders of orgasm25
Disorders of Orgasm
  • Male orgasmic disorder
    • Characterized by a repeated inability to reach orgasm or by a very delayed orgasm after normal sexual excitement
      • Occurs in 8% of the male population
    • Biological causes include low testosterone, neurological disease, and head or spinal injury
      • Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the CNS, can also affect ejaculation
disorders of orgasm26
Disorders of Orgasm
  • Male orgasmic disorder
    • A leading psychological cause appears to be performance anxiety and the spectator role, the cognitive factors involved in ED
disorders of orgasm27
Disorders of Orgasm
  • Female orgasmic disorder
    • Characterized by persistent delay in or absence of orgasm following normal sexual excitement
      • Almost 25% of women appear to have this problem
        • 10% or more have never reached orgasm
        • An additional 10% reach orgasm only rarely
      • Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly
      • Female orgasmic disorder appears more common in single women than in married or cohabiting women
disorders of orgasm28
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
    • Typically linked to female sexual arousal disorder
      • The two disorders tend to be studied and treated together
    • Once again, biological, psychological, and sociocultural factors may combine to produce these disorders
disorders of orgasm29
Disorders of Orgasm
  • Female orgasmic disorder
    • Biological causes
      • A variety of medical 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
        • For example, as many as 40% of women who take Prozac and other SSRIs may have problems with orgasm or arousal
      • Postmenopausal changes may also be responsible
disorders of orgasm30
Disorders of Orgasm
  • Female orgasmic disorder
    • Psychological causes
      • The psychological causes of hypoactive sexual desire and sexual aversion may also lead to female arousal and orgasmic disorders
      • Memories of childhood trauma and relationship distress may also be related
disorders of orgasm31
Disorders of Orgasm
  • Female orgasmic disorder
    • Sociocultural causes
      • For decades, the leading sociocultural theory of female sexual dysfunction 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
disorders of orgasm32
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 certain qualities in a woman’s intimate relationships (such as emotional intimacy) to orgasmic behavior
disorders of sexual pain
Disorders of Sexual Pain
  • Two sexual dysfunctions do not fit neatly into a specific phase of the sexual response cycle
    • These are the sexual pain disorders:
      • Vaginismus
      • Dyspareunia
disorders of sexual pain34
Disorders of Sexual Pain
  • Vaginismus
    • Characterized by involuntary contractions of the muscles of the outer third of the vagina
      • Severe cases can prevent a woman from having intercourse
      • Perhaps 20% of women occasionally have pain during intercourse, but less than 1% of all women have vaginismus
disorders of sexual pain35
Disorders of Sexual Pain
  • Vaginismus
    • Most clinicians agree with the cognitive-behavioral theory that vaginismus is a learned fear response
      • A variety of factors can set the stage for this fear, including anxiety and ignorance about intercourse, trauma caused by an unskilled partner, and childhood sexual abuse
    • Some women experience painful intercourse because of infection or disease, leading to “rational” vaginismus
    • Most women with vaginismus also have other sexual disorders
disorders of sexual pain36
Disorders of Sexual Pain
  • Dyspareunia
    • Characterized by severe pain in the genitals during sexual activity
      • Affects almost 15% of women and about 3% of men
    • Dyspareunia in women usually has a physical cause, most commonly from injury sustained in childbirth
    • Although relationship problems or psychological trauma from abuse may contribute to dyspareunia, psychosocial factors alone are rarely responsible
treatments for sexual dysfunctions
Treatments for Sexual Dysfunctions
  • The last 35 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 negotiate the stages of psychosexual development
      • Therapy focused on gaining insight and making broad personality changes; was generally unhelpful
treatments for sexual dysfunctions38
Treatments for Sexual Dysfunctions
  • 1950s and 1960s: behavioral therapy
    • Behavioral therapists attempted to reduce fear by applying relaxation training and systematic desensitization
    • Had moderate success, but failed to work in cases where the key problems were cognitive or psychoeducational
treatments for sexual dysfunctions39
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, multidimensional approach
      • Includes techniques from cognitive, behavioral, couples, and family systems therapies
      • More recently, biological interventions have also been incorporated
what are the general features of sex therapy
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
what are the general features of sex therapy41
What Are the General Features of Sex Therapy?
  • Modern sex therapy includes:
    • Assessing and conceptualizing the problem
    • Assigning “mutual responsibility” for the problem
    • Education about sexuality
    • Attitude change
    • Elimination of performance anxiety and the spectator role
    • Increasing sexual communication skills
    • Changing destructive lifestyles and marital interventions
    • Addressing physical and medical factors
what techniques are applied to particular dysfunctions
What Techniques Are Applied to Particular Dysfunctions?
  • In addition to the universal components of sex therapy, specific techniques can help in each of the sexual dysfunctions
what techniques are applied to particular dysfunctions43
What Techniques Are Applied to Particular Dysfunctions?
  • Hypoactive sexual desire and sexual aversion
    • 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
what techniques are applied to particular dysfunctions44
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”
    • Biological approaches, used when the ED has biological causes, have gained great momentum with the recent approval of sildenafil (Viagra)
      • Most other biological approaches have been around for decades and include gels, suppositories, penile injections, a vacuum erection device (VED), and penile implant surgery
what techniques are applied to particular dysfunctions45
What Techniques Are Applied to Particular Dysfunctions?
  • Male orgasmic disorder
    • Like treatment for ED, 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 nervous system
what techniques are applied to particular dysfunctions46
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” technique
    • Some clinicians favor the use of fluoxetine (Prozac) and other serotonin-enhancing antidepressant drugs
      • Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation
      • While some studies have reported positive findings, long-term outcome studies have yet to be conducted
what techniques are applied to particular dysfunctions47
What Techniques Are Applied to Particular Dysfunctions?
  • Female arousal and orgasmic disorders
    • Specific treatment techniques for these disorders include self-exploration, enhancement of body awareness, and directed masturbation training
    • Again, a lack of orgasm during intercourse is not necessarily a sexual dysfunction, provided the woman enjoys intercourse and is orgasmic through other means
      • For this reason, some therapists believe that the wisest course of action is simply to educate women whose only concern is lack of orgasm through intercourse
what techniques are applied to particular dysfunctions48
What Techniques Are Applied to Particular Dysfunctions?
  • Vaginismus
    • Specific treatment for vaginismus takes two approaches:
      • Practice tightening and releasing the muscles of the vagina to gain more voluntary control
      • Overcome fear of intercourse through gradual behavioral exposure treatment
    • Over 75% of women treated for vaginismus using these methods eventually report pain-free intercourse
what techniques are applied to particular dysfunctions49
What Techniques Are Applied to Particular Dysfunctions?
  • Dyspareunia
    • Determining the specific cause of dyspareunia is the first stage of treatment
      • Given that most cases are caused by physical problems, medical intervention may be necessary
what are the current trends in sex therapy
What Are the Current Trends in Sex Therapy?
  • Over the past 30 years, sex therapists have moved beyond the approach first developed by Masters and Johnson
    • Therapists now treat unmarried couples, those with other psychological disorders, couples with severe marital discord, the elderly, the medically ill, the physically handicapped, clients with a homosexual orientation, and clients with no long-term sex partner
what are the current trends in sex therapy51
What Are the Current Trends in Sex Therapy?
  • Therapists are paying more attention to excessive sexuality, which is sometimes called sexual addiction
  • The use of medications to treat sexual dysfunction is troubling to many therapists
    • They are concerned that therapists will choose biological interventions rather than a more integrated approach
  • These disorders are characterized by unusual fantasies and sexual urges or behaviors that are recurrent and sexually arousing
    • Often involve:
      • Humiliation of self or partner
      • Children
      • Nonconsenting people
      • Nonhuman objects
  • According to the DSM, paraphilias should be diagnosed only when the urges, fantasies, or behaviors last at least 6 months
    • For most paraphilias, the urges, fantasies, or behaviors must also cause great distress or impairment
      • For certain paraphilias, however, performance of the behavior itself is indicative of a disorder
        • Example: sexual contact with children
  • Some people with one kind of paraphilia display others as well
    • Relatively few people receive a formal diagnosis, but clinicians believe that the patterns may be quite common
  • Although theorists have proposed various explanations for paraphilias, there is little formal evidence to support the theories
    • None of the treatments applied to paraphilias have received much research or proved clearly effective
      • Recent work has focused on biological interventions
  • The key features of fetishism are recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object
    • The disorder usually begins in adolescence
    • Almost anything can be a fetish
      • Women’s underwear, shoes, and boots are especially common
  • Researchers have been unable to pinpoint the causes of fetishism
    • Psychodynamic theorists view fetishes as defense mechanisms, but therapy using this model has been unsuccessful
  • Behaviorists propose that fetishes are learned through classical conditioning
    • Fetishes are sometimes treated with aversion therapy, covert sensitization, or imaginal exposure
    • Another behavioral treatment is masturbatory satiation, in which clients masturbate to boredom while imagining the fetish object
    • An additional behavioral treatment is orgasmic reorientation, a process which teaches individuals to respond to more appropriate sources of sexual stimulation
transvestic fetishism
Transvestic Fetishism
  • Also known as transvestism or cross-dressing
  • Characterized by fantasies, urges, or behaviors involving dressing in the clothes of the opposite sex in order to achieve sexual arousal
transvestic fetishism59
Transvestic Fetishism
  • The typical person with transvestism is a heterosexual male who began cross-dressing in childhood or adolescence
  • Transvestism is often confused with gender identity disorder (transsexualism), but the two are separate patterns
  • The development of the disorder seems to follow the behavioral principles of operant conditioning
  • Characterized by arousal from the exposure of genitals in a public setting
    • Also known as “flashing”
    • Sexual contact is neither initiated nor desired
  • Usually begins before age 18
  • Treatment generally includes aversion therapy and masturbatory satiation
    • May be combined with orgasmic reorientation, social skills training, or psychodynamic therapy
  • Characterized by repeated and intense sexual desires to observe people in secret as they undress or to spy on couples having intercourse; may involve acting upon these desires
    • The person may masturbate during the act of observing or while remembering it later
    • The risk of discovery often adds to the excitement
  • Many psychodynamic theorists propose that voyeurs are seeking power
    • Others have explained it as an attempt to reduce fears of castration
  • Behaviorists explain voyeurism as a learned behavior that can be traced to a chance and secret observation of a sexually arousing scene
  • A person who develops frotteurism has fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person
    • Almost always male, the person fantasizes during the act that he is having a caring relationship with the victim
  • Usually begins in the teenage years or earlier
    • Acts generally decrease and disappear after age 25
  • Characterized by fantasies, urges, or behaviors involving sexual activity with a prepubescent child, usually 13 years of age or younger
    • Some people are satisfied with child pornography
    • Others are driven to watching, fondling, or engaging in intercourse with children
    • Victims may be male, but evidence suggests that two-thirds are female
  • People with pedophilia develop the disorder in adolescence
    • Some were sexually abused as children
      • Many were neglected, excessively punished, or deprived of close relationships in childhood
    • Most are immature, display faulty thinking, and have an additional psychological disorder
      • Some theorists have proposed a related biochemical or brain structure abnormality
  • Most people with pedophilia are imprisoned or forced into treatment
    • Treatments include aversion therapy, masturbatory satiation, and orgasmic reorientation
    • Cognitive-behavioral treatment involves relapse-prevention training, modeled after programs used for substance dependence
sexual masochism
Sexual Masochism
  • Characterized by fantasies, urges, or behaviors involving the act or thought of being humiliated, beaten, bound, or otherwise made to suffer
  • Most masochistic fantasies begin in childhood and seem to develop through the behavioral process of classical conditioning
sexual sadism
Sexual Sadism
  • A person with sexual sadism finds fantasies, urges, or behaviors involving the thought or act of psychological or physical suffering of a victim sexually exciting
    • Named for the infamous Marquis de Sade
    • People with sexual sadism imagine that they have total control over a sexual victim
sexual sadism69
Sexual Sadism
  • Sadistic fantasies may first appear in childhood
    • Pattern is long-term
    • Appears to be related to classical conditioning and/or modeling
  • Psychodynamic and cognitive theorists view people with sexual sadism as having underlying feelings of sexual inadequacy
sexual sadism70
Sexual Sadism
  • Biological studies have found possible abnormalities in the endocrine system
  • The primary treatment for this disorder is aversion therapy
a word of caution
A Word of Caution
  • The definitions of paraphilias, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur
  • Some clinicians argue that, except when people are hurt by them, paraphilic behaviors should not be considered disorders at all
gender identity disorder
Gender Identity Disorder
  • Gender identity disorder, or transsexualism, is one of the most fascinating disorders related to sexuality
    • People with this disorder persistently feel that they have been assigned to the wrong biological sex
      • They would like to remove their primary and secondary sex characteristics and acquire the characteristics of the opposite sex
gender identity disorder73
Gender Identity Disorder
  • Men with GID outnumber women 2 to 1
  • People with GID often experience anxiety or depression and may have thoughts of suicide
gender identity disorder74
Gender Identity Disorder
  • People with gender identity disorder usually feel uncomfortable wearing the clothes of their own sex and may cross-dress
    • This is distinctly different from a transsexual fetish; there is no sexual arousal related to this disorder
  • The disorder sometimes emerges in childhood and disappears with adolescence
    • In some cases it develops into adult gender identity disorder
gender identity disorder75
Gender Identity Disorder
  • Several theories have been proposed to explain this disorder, but research is limited and generally weak
    • Some clinicians suspect biological factors
      • Abnormalities in the hypothalamus (particularly the bed nucleus of stria terminalis) are a potential link
  • Some adults with this disorder change their sexual characteristics by way of hormones; others opt for sexual reassignment (sex-change) surgery