Chapter 13: Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders

Question 1

Sexual Dysfunctions

Answer 1

characterized by a clinically significant impairment in one’s ability to respond sexually or to experience sexual pleasure. It is important to note that some people may have many characteristics of a sexual dysfunction yet not be distressed by them, and in these cases, a diagnosis would not be made.

Question 2

Ex: Sexual Dysfunction

Answer 2

an individual may have significant issues with obtaining and maintaining their penile erections, yet they may also derive much pleasure and satisfaction with their partner through activities that do not require an erect penis.

Question 3

Diagnosing SD

Answer 3

can be challenging at times, especially because some of the diagnoses require the clinician to make somewhat subjective judgments: to decide, for example, whether a client’s experiences are “persistent,” “recurrent,” or “delayed.”

Question 4

Gender Dysphoria

Answer 4

For the diagnosis of gender dysphoria, feelings of distress are experienced due to, for example, the absence of congruence between one’s birth-assigned sex and one’s gender identity.

Question 5

Gender

Answer 5

refers to the socio-cultural aspects of being a man, woman, or person of any gender,

Question 6

Sex

Answer 6

refers to the biological aspects (e.g., anatomy, hormones, chromosomes).

Question 7

Trans

Answer 7

in the case of transgender individuals, it refers to one’s identity being on a different side of one’s sex assigned at birth.

Question 8

Cisgender

Answer 8

it indicates that one’s gender identity is on the same side as one’s sex.

Question 9

Non-Binary (enby), bi gender, agender, and many other terms

Answer 9

to convey that fitting into one gender or the other does not resonate with how they see themselves or how they wish to be viewed by others.

Question 10

Intersex

Answer 10

refers to diversities of biological sex due to a variety of processes (e.g., hormonal, chromosomal) that exist outside of or are not seen as fitting norms of the binary sexes of male and female, and often involve unwanted medical attention. For example, some individuals have sex chromosomes that vary from XX (typically female) and XY (typically male), such as XXY (Klinefelter’s Syndrome) and XO (Turner’s Syndrome)

Question 11

Gender dysphoria

Answer 11

It refers to distress experienced due to, for example, an incongruence between one’s gender and one’s birth-assigned sex (the sex assigned at birth based solely on genital anatomy).

Question 12

Paraphillias

Answer 12

intense and persistent atypical sexual interests—cannot be diagnosed as a disorder unless the individual experiences distress or impairment because of the paraphilia, or it harms others. For example, a person who engages in sexual sadism with consenting, adult partners as part of a kinky lifestyle and who is not distressed by this behaviour would simply have a paraphilia called sexual sadism, but one who engages in this behaviour and harms others would be diagnosed with sexual sadistic disorder.

Question 13

Paraphilic interest is necessary but not sufficient conditions for having a

Answer 13

Paraphillic disorder

Question 14

Paraphilic disorder involves

Answer 14

get into trouble with the law due to the harm of others and/or breaking the law (e.g., trespassing, indecent exposure), which is one major factor that differentiates paraphilic disorders from sexual dysfunctions and gender dysphoria.

Question 15

Homosexuality

Answer 15

No longer considered a disorder

Question 16

Sexual orientation disorder

Answer 16

to refer to those who were attracted to members of the same gender/sex and experienced conflict with their sexual orientation or who wished to change their orientation.

Question 17

Egodystonic homesexuality

Answer 17

A disorder (not currently in use) in which the person is attracted to people of the same sex, but experiences conflict with their sexual orientation or wishes to change it.

Question 18

Sexual Response Cycle

Answer 18

The sequence of changes that occur in the body with increased sexual arousal, orgasm, and the return to the unaroused state, noted by William Masters and Virginia Johnson.

Question 19

Excitement stage

Answer 19

enital tissues swell as they fill with blood (vasocongestion). This process causes penile erection, engorgement of the clitoris, and vaginal lubrication. Furthermore, the testes and nipples become engorged, muscular tension and heart rate increase, and breathing becomes more rapid and shallow.

Question 20

Plateua stage

Answer 20

consolidates this arousal, with additional swelling of the penis and vulvar/vaginal tissues. The testes become elevated and may reach one and a half times their unaroused size. The clitoris retracts underneath the clitoral hood and the inner part of the vagina expands.

Question 21

Orgasm

Answer 21

rhythmic, muscular contractions in the genital region occur at about eight-second intervals. Penile orgasm usually comprises two stages, which quickly follow one another. First, seminal fluid collects in the urethral bulb, at the base of the penis. As this process occurs, there is a sense of orgasmic inevitability that signals impending ejaculation. Within two or three seconds, contractions lead to expulsion of the ejaculate. In those with uteruses and vaginas, the uterus and muscles surrounding the vagina contract during orgasm. Blood pressure and heart rate reach a peak during orgasm, and there are involuntary muscular contractions. Following orgasm, the body gradually returns to its pre-aroused state, in the stage that Masters and Johnson called resolution

Question 22

Four stages in sexual response: Excitement, platau, orgasm, and resolution for binary gender/sexes

Question 23

Resolution phase

Answer 23

the level of sexual arousal returns to the pre-aroused state. For some people with penises, there may be a refractory period following orgasm. As shown by the broken line, however, orgasm can be possible once past the refractory period (which can last a few seconds to hours/days depending on many factors, including age) and when levels of sexual arousal have returned to pre-plateau levels.

Question 24

There can be many sequences of sexual response to exist

Answer 24

Thus, a sexual encounter may sometimes involve excitement followed by diminished arousal without orgasm.

Question 25

Sexual dysfunctions: Categories and Subtypes

Answer 25

Sexual dysfunctions can be further characterized

Question 26

Sexual Desire and Arousal Disorders Subtypes

Answer 26

Sexual interest/Arousal Disorder (female)
Hypoactive sexual desire disorder
Erectile disorder

Question 27

Orgasmic disorders Subtypes

Answer 27

Delayed ejaculation
Orgasmic Disorder
Premature (early) Ejaculation (male)

Question 28

Lifelong Sexual Dysfunction

Answer 28

if the person has always experienced the problem,

Question 29

Acquired sexual dysfunction

Answer 29

Any sexual dysfunction that the sufferer has developed after a dysfunction-free period of time.

Question 30

generalized sexual dysfunctions

Answer 30

Any sexual dysfunction that is apparent in all sexual situations, including with the person’s sexual partners and during solitary sexual activity.

Question 31

Situational Sexual Dysfunctions

Answer 31

Any sexual dysfunction that is apparent only in a specific sexual situation, for example, with a certain sexual partner.

Question 32

Hyperactive sexual desire disorder

Answer 32

A sexual dysfunction characterized by persistent or recurrent deficiency of sexual fantasies and desire for sex, causing marked distress or interpersonal difficulty.

Question 33

Sexual Interest/Arousal Disorder

Answer 33

A sexual dysfunction characterized by a lack of, or significantly reduced sexual arousal/interest (e.g., reduced sexual thoughts and sexual pleasure) for a minimum of six months in 75% to 100% of sexu

Question 34

Hypoactive

Answer 34

Implies an established standard

Question 35

Sexual arousal disorders

Answer 35

arousal disorders involve difficulty becoming physically aroused when the person desires such arousal. In those with penises, sexual arousal, or lack thereof, is usually gauged by penile erection, not the only physiological response but certainly the most obvious.

Question 36

Erectile disorder

Answer 36

haracterized by difficulties with obtaining an erection during sexual activity, maintaining an erection until the completion of sexual activity, and/or a marked decrease in erectile rigidity in 75% to 100% of sexual occasions. These symptoms must be distressing and be present for a minimum of six months. Erectile disorder is a commonly reported sexual dysfunction (McCabe et al., 2016a). Several factors can influence the rates of erectile disorder, including smoking, heart disease, and age, the last factor being particularly important given that the prevalence of erectile disorder increases with age

Question 37

Female Orgasmic Disorders

Answer 37

A sexual dysfunction characterized by a delay in, infrequency of, or absence of orgasm and/or a reduction in the intensity of orgasmic sensations in all or almost all (75% to 100%) occasions of sexual activity for a minimum of six months, causing marked distress or interpersonal difficulty. Also known as anorgasmia.

Question 38

Orgasm gap

Answer 38

refers to a notable difference in orgasm frequency between women and men during penetrative sexual activity, such that women report lower orgasm frequency than do men

Question 39

Delayed Ejaculation

Answer 39

is diagnosed when there is a marked delay in ejaculation or a marked infrequency or absence of ejaculation that is present in 75% to 100% of sexual occasions with a partner and for a minimum duration of six months.

the individual must not desire the delay and must be distressed about the symptoms

Question 40

Premature or early ejaculation

Answer 40

A sexual dysfunction characterized by ejaculation within approximately one minute of vaginal penetration during 75% to 100% of occasions of sexual activity for a minimum of six months, with marked distress.

Question 41

Genito Pelvic Pain/Penetration Disorder

Answer 41

A sexual dysfunction characterized by persistent or recurrent difficulties with one or more of the following: vaginal penetration during intercourse; marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts; marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration; and marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration on 75% to 100% of sexual occasions for at least six months, resulting in distress.

Question 42

Hypersexuality

Answer 42

Excessive interest or involvement in sexual activity at levels high enough to become clinically significant.

Question 43

“hyperaesthesia”

Answer 43

excessively increased sexual desire

Question 44

Nymphomania

Answer 44

excessive desire in women

Question 45

Satyriasis

Answer 45

excessive desire in men

Question 46

Hypersexuality

Answer 46

typically report experiencing a loss of control over sexual urges, fantasies, and behaviours, and they often engage in sexual activity to regulate negative emotional states (e.g., anxiety, depression)

Question 47

Atheoretical treatment-focused models

Answer 47

For example, it is important to examine those with hypsersexuality who are, or are not, paraphilic. Other subtypes include (1) those who present with problems with pornography and masturbation, (2) those with infidelity and multiple partner issues, and (3) those “designated” as patients by their partners or their own imposed (religious) norms around “normal” sexuality

Question 48

Risk factors of Sexual Dysfunctions

Answer 48

diabetes, heart disease, urinary tract disorders, chronic illness, depression and anxiety (as well as the medications used to treat these disorders), substance abuse, and psychosocial factors (e.g., poor relationship quality)

Question 49

High levels of depressive symptoms

Answer 49

correlation between high levels of depressive symptoms and reduced levels of sexual desire

Question 50

Reasons for sexual Desire Disorders

Answer 50

dysfunctional attitudes about sex, relationship problems, and a strict upbringing that associated sexual pleasure with guilt. A history of sexual abuse, emotional neglect, and other traumatic experiences (e.g., sexual harassment) has been associated with low sexual desire

Cognitive factors (e.g., stress, distraction, anxiety, self-consciousness) have been implicated in addition to relationship factors (e.g., sexual dysfunction in the partner/s, relationship duration and satisfaction, quality of communication

Question 51

Performance anxiety and sexual dysfunctions

Answer 51

is the response of individuals who feel that they are expected to perform sexually.

Worried that their performance will not be up to the expectations of their partner, they become spectators of their own behaviour, monitoring their own sexual performance and the perceived responses of their partner. When this happens, the person’s focus is on the performance rather than on enjoyment of the sexual experience.

Question 52

Hormone Imbalances can also play a role

Answer 52

ertainly, hormones such as estrogens, androgens, and prolactin are involved in sexual activity and desire, and variations in the levels of these hormones can lower or increase sex drive

Question 53

Erectile disorder involves a complex interplay between physiological and psychological factors.

Answer 53

cardiovascular disease, neurological diseases, damage due to pelvic surgery, or various medications, whereas psychological factors include performance anxiety (described above), stress, mood disorders, problems in the relationship, and psychological traumas

Question 54

Risk factors for erectile disorder

Answer 54

include age, diabetes, hypertension, cigarette smoking, and alcoholism (Russell & Nehra, 2003). Hormonal factors have also been proposed, where a loss of androgens may contribute to erectile dysfunction. Overall, both psychological and physiological factors are important and should be considered in a comprehensive assessment by a multidisciplinary team.

Question 55

Premature (Early) Ejaculation

Answer 55

Several factors have been implicated in premature (early) ejaculation. For example, genetic factors involved in the sensitivity of the ejaculatory response may play a role, as can the presence of erectile disorder, anxiety, hyperthyroidism, and prostatic inflammation or infection (Donatucci, 2006). In addition, sexual conditioning is important to assess; some individuals develop a habit of masturbating quickly and efficiently, which over time may generalize to other sexual situations (recall Mo’s experience). Furthermore, a low frequency of ejaculation (Donatucci, 2006), younger age, and life stressors such as relationship or work dissatisfaction (Corona et al., 2004; Corona et al., 2006) have been implicated.

Question 56

Genito-Pelvic Pain/Penetration Disorder (GPPPD)

Answer 56

GPPPD can result from underlying physical pathologies such as pelvic floor muscle dysfunction, endometriosis, interstitial cystitis, lichen sclerosus, and genital infections (e.g., candidiasis, herpes, bacterial vaginosis; Pukall et al., 2016). Psychosocial factors also play an important role in the onset and maintenance of GPPPD (Bergeron, Rosen, Pukall, & Corsini-Munt, 2020). For example, childhood victimization, anxiety and depression, and relationship factors have been found to play a role in the expression of GPPPD. In addition, cognitive factors such as pain catastrophizing, hypervigilance to pain, lower pain self-efficacy, and negative attributions about the pain—all of which may lead to an avoidance of sexual activity—have been associated with increased pain in GPPPD

Question 57

Treatments for Sexual Dysfunctions

Answer 57

Effective sexual communication first requires each partner to develop an understanding of their own sensations and bodily response. Acceptance of their own bodies may be limited because of embarrassment or guilt.

Question 58

Sensate focus

Answer 58

essentially a form of desensitization applied to sexual fears. It is assumed that once the sexual dysfunction has emerged, the person develops performance anxiety or fear, which serves to worsen and entrench the problem.

Sensate focus involves a series of exercises where partners engage in predetermined stages of sexual interaction (Weiner & Avery-Clark, 2014). In the first step, they undress together with the light on to desensitize any embarrassment they may have about being naked together. They next take turns at massaging or touching one another all over, except for the genital or breast areas. They are learning to enjoy touching and being touched without any fear of imminent demands for sex. After several sessions of this, each person begins to tell the partner during the touching exercises what each enjoys.

Question 59

Stop-start and squeeze techniques

Answer 59

behavioural approaches used to treat premature (early) ejaculation, and can be used either with or without a partner (Cooper et al., 2015). With the stop-start technique, manual stimulation of the penis occurs until the earliest signs of approaching orgasm are perceived, at which point stimulation is stopped. After a period of time (approximately 40 seconds to 1 minute), stimulation recommences. This procedure is repeated so that the entire process lasts approximately 15 minutes (employing as many stops as is necessary). Sometimes, just stopping is not enough to prevent ejaculation. In those cases, the squeeze technique is employed by squeezing around the coronal ridge of the penis. Although it is not painful, the squeeze technique diminishes arousal and prevents ejaculation. When the individual can last approximately 15 minutes with only one or two “stops,” the couple can proceed to more arousing stimulation methods (e.g., oral sex)

Question 60

Vaginal dilation

Answer 60

(i.e., the use of dilators to aid in relaxing the vaginal opening), is recommended for those who have GPPPD. Vaginal dilatation involves the gradual insertion of dilators of increasing diameter during general body (e.g., deep breathing) and pelvic floor muscle relaxation exercises to normalize muscle tone

Question 61

phosphodiesterase inhibitors (PDE5 inhibitors) designed to treat erectile disorders

Answer 61

sildenafil (marketed under the trade name Viagra), tadalafil (Cialis), and vardenafil (Levitra), and all restrict the breakdown of cyclic guanine monophosphate, which leads to increased blood flow and stronger erections. Each medication has been approved by Health Canada, although some adverse side effects have been noted (e.g., problems with vision). Some patients prefer one type over another, given differences with regard to duration of action (Viagra has the shortest duration at four to six hours and Cialis has the longest duration, up to 36 hours) and interactions with fatty foods

Question 62

PDE5 Inhibitors

Answer 62

Given the encouraging results and typically mild side effects, these drugs have become the first-line medical treatment option for erectile disorder, with intracavernous treatment being recommended as second-line.

Question 63

transurethral therapy- erectile disorder

Answer 63

tracavernous treatment, via self-injection of smooth muscle relaxants (e.g., phentolamine, papaverine, and alprostadil) into the corpus cavernosum of the penis, facilitates an erection by relaxing smooth muscle tissue

Question 64

Alprostadil, in particular, represents the most common form of intracavernous treatment

Answer 64

for erectile dysfunction and, upon administration, erections may last for about an hour, irrespective of whether there is direct sexual stimulation. Erections typically occur within 10 minutes, and side effects include mild pain and priapism (Shamloul & Ghanem, 2013); however, studies have shown that this type of treatment is efficacious and safe (for a review, see

Question 65

Transurethral therapy consists

Answer 65

of the insertion of an erectogenic drug (usually alprostadil) in the form of a pellet into the urethra with a small applicator. Side effects include penile and/or urethral pain, syncope, and priapism (Shamloul & Ghanem, 2013). Studies have reported a rate of 49% to 66% for erections that are sufficient for intercourse and a rate of 64% for successful intercourse, but other studies have reported much lower success rates

Question 66

Antidepressants (SSRIs)

Answer 66

have also been used off-label, typically in the treatment of premature (early) ejaculation, as they have demonstrated the ability to delay the ejaculatory response and have led to improved sexual satisfaction

Question 67

Pelvic floor physiotherapy

Answer 67

emerged as a potential treatment for men with erectile dysfunction (primarily in the UK; Dorey et al., 2004), although the use of vacuum erection devices is more common. Both retrospective (Bergeron et al., 2002) and prospective studies (Goldfinger, Pukall, Gentilcore-Saulnier, McLean, & Chamberlain, 2009) have documented positive outcomes of pelvic floor physiotherapy for GPPPD in terms of pain reduction and improvements in sexuality after treatment.

Question 68

Surgical interventions are also recommended for some individuals with sexual dysfunctions

Answer 68

vestibulectomy (surgical removal of the superficial vestibule) for women with a particular form of GPPPD called provoked vestibulodynia is the most commonly reported treatment and has positive outcomes (Bergeron et al., 2020). Penile implants for those with erectile disorder are typically recommended as an option after other treatments (drugs, injections) have yielded unsatisfactory results. While a number of different implants were used in the past, the most popular approach is to implant inflatable silicone cylinders in the penis

Question 69

“Two-Spirit”

Answer 69

Indigenous individuals who express diverse masculine and feminine spirits; this term is usually used by many Indigenous individuals when describing not only their gender/sex and sexual identity, but also their spiritual identity and connection to Indigeneity.

Question 70

Gender identity

Answer 70

a person’s sense of self as boy/man, girl/woman, both, or something else, the first signs of which appear between 18 and 36 months of age; Money, 1987) may align with one’s birth-assigned sex, and it may change over time, as can dimensions of sex (e.g., with puberty or bodily gender affirmation).

Question 71

Gender expression

Answer 71

is how a person publicly expresses their gender through, for example, their behaviour, outward appearance, chosen name, and pronoun.

Question 72

Gender role

Answer 72

is the collection of those characteristics that a society defines as masculine, feminine, or androgynous. Because roles relate to social standards, ideas about gender roles change over time and vary among cultures. In some instances, these “variables of sex/gender” do not all coincide

Question 73

Intersex

Answer 73

variation may be reflected, with the reproductive structures or genital anatomy presenting as different from what is typically considered to be “male” or “female.”

Question 74

Gender dysphoria

Answer 74

When biological variables are coincident with each other, but are discordant or branched with the person’s sense of self,

Question 75

Gender Identity disorder

Answer 75

Several studies have reported evidence indicating a significant heritable pattern for children with gender identity disorder (GID), the diagnosis that existed prior to gender dysphoria

It has also been proposed that an “excess” or absence of testosterone during a critical point in fetal development may affect the individual’s gender identity. One of the most predominant neurobiological theories for the development of gender dysphoria has focused on the role of prenatal hormones. In particular, prenatal exposure to male-typical levels of androgens is theorized to masculinize postnatal behaviour, whereas “underexposure” to male-typical levels of androgens has the opposite effect

Question 76

Treatments

Answer 76

Some, but not all, people with gender dysphoria request hormonal treatment or surgery to align their body with their identified gender/sex

Question 77

The Standards of Care include the following minimum eligibility criteria for gender-affirming surgery:

Answer 77

1) persistent, well-documented gender dysphoria; (2) capacity to make a fully informed decision and to consent for treatment; (3) age of majority in a given country; (4) if significant medical or mental health concerns are present, they must be well controlled; and (5) 12 continuous months of hormone therapy (unless medical issues preclude the use of hormones).

Question 78

Hormonal therapy

Answer 78

assists in developing the desired secondary sex characteristics (Dickey & Steiner, 1990) and is a crucial aspect in mental health outcomes

Question 79

Those who were assigned male sex at birth and who were treated with androgen-suppressing and estrogenic hormones

Answer 79

how breast enlargement, skin softening, increased fat deposits, and decreased muscle bulk, as well as decreased facial and body hair.

Question 80

Treatment of those who were assigned female sex at birth with estrogen-suppressing and androgenic hormones leads

Answer 80

to an increase in muscle bulk, facial hair and body hair, potential receding and loss of head hair, deepening of the voice, enlargement of the clitoris, increased libido, and suppression of ovarian function.

Question 81

Paraphillias

Answer 81

paraphilias are characterized by “intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners”

Question 82

Paraphillic disorder

Answer 82

as a paraphilia that currently causes distress or impairment to the individual, or a paraphilia that causes personal harm, or risk of harm, to others when acted upon. According to this perspective, which has taken decades for the DSM to adopt, if a clinician ascertained the presence of a paraphilia, it would not necessarily require psychiatric diagnosis or intervention. Only in the case that this paraphilia caused distress to the individual experiencing it or harm to others would it then be diagnosed as a paraphilic disorder. In addition, the criterion for the paraphilic disorders that involves nonconsenting persons is more specific in terms of the number of nonconsenting persons involved, and this number varies depending on the paraphilic disorder.

Question 83

Fetishistic disorder

Answer 83

as recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on a nongenital body part or parts. Fetish objects are not limited to articles of clothing used in cross-dressing or devices designed for genital stimulation (e.g., a vibrator). As with all of the paraphilic disorders, the fetish needs to have occurred over a period of at least six months, as manifested by fantasies, urges, or behaviours. For this to be a paraphilic disorder, as opposed to a fetish (a paraphilia), there needs to be clinically significant distress or impairment in functioning

-women’s underwear or shoes

Question 84

Apotemnophilia

Answer 84

is the fetish for amputation and genital mutilation. One case was even documented where a man cut off his own penis due to a genital mutilation fetish (Lowenstein, 2002). Many individuals have more than one fetish

Question 85

Other fetishes

Answer 85

typically like to smell or rub the object against their bodies or, in some cases, wear the article or have their partner wear it.

Question 86

Transvestic disorder

Answer 86

When the articles worn by the person with the fetish are clothes of the other sex and this behaviour is considered distressing

Question 87

Transvestic disorder

Answer 87

According to the DSM-5-TR, a person who cross-dresses—wears the clothing associated with the other sex—to produce or enhance sexual excitement is said to have transvestism. If this cross-dressing (or fantasies or urges to cross-dress for sexual excitement) occurs over a period of at least six months and causes significant distress or impairment, it becomes transvestic disorder, as opposed to transvestism. Although the prevalence of transvestic disorder is not known, it appears to be more common in men than women

Question 88

Sexual sadism

Answer 88

describes a sexual preference toward inflicting pain or psychological suffering on others.

Question 89

Sexual masochism

Answer 89

describes individuals who enjoy experiencing pain or humiliation from another individual.

Question 90

Sexual sadism and masochism

Answer 90

diagnosed when the individual has acted upon these sexual urges with a nonconsenting person (in the case of sadism), or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Question 91

BDSM

Answer 91

refers specifically to bondage and discipline, domination and submission, and sadism and masochism. Many sadists and masochists in the context of BDSM are generally well-adjusted individuals with otherwise conventional lifestyles.

Question 92

Sexual sadism

Answer 92

occurs when a person experiences sexual pleasure from inflicting physical pain or psychological suffering on another person, often to gain power or to humiliate the other person. Those with the disorder find ritualized sadism with a willing partner to be unsatisfying and seek out nonconsenting partners, thus satisfying the definition of a sexual offence. These individuals will be considered in more detail in the later section dealing with sexual assault.

Question 93

Sexual masochism

Answer 93

can include behaviours that range from harmless (likely not meeting the definition of a disorder), such as being restrained, to potentially dangerous and meeting criteria for a sexual masochism disorder, such as hypoxyphilia (also known as autoerotic asphyxia or asphyxiophilia), a paraphilic interest that strongly overlaps with masochism, with 71% to 99% of those who partake in autoerotic asphyxia identifying as masochists

Question 94

Exhibitionistic Disorder

Answer 94

exhibitionism (i.e., exposing one’s genitals to an unsuspecting and nonconsenting individual or individuals) is the most frequently occurring sexual offence in Western countries. According to one survey, just over 40% of university women had been victims of exhibitionism

They found that a substantial number of exhibitionists go on to commit more serious “hands-on” sexual offences and that such individuals are at greater risk for committing another offence when compared to other types of sexual offenders

Question 95

Dick picks and exhibitionist disorder

Question 96

Voyeuristic disorder

Answer 96

Voyeurs are individuals who experience recurrent and intense sexually arousing urges/fantasies or behaviours involving the observation of unsuspecting individuals who are naked, disrobing, or engaged in sexual activity

An essential feature of this disorder is that the person of interest must be unaware that they are being watched. Usually, voyeurs do not seek sexual relations with the person being watched and will often masturbate while engaged in the voyeuristic activity or later in response to the memory of what the person has witnessed. The DSM-5-TR specifies that voyeuristic disorder cannot be diagnosed in individuals under the age of 18, in order to avoid pathologizing normative sexual interest and behaviour during puberty.

Question 97

Frotteuristic disorder

Answer 97

Almost all detected frotteurs are male. Frotteurism (or frottage—from the French frotter, “to rub”), according to the DSM-5-TR refers to touching or rubbing up against a noncompliant person so that the frotteur can become sexually aroused and, in many cases, reach orgasm

crowded places such as busy sidewalks, stores, or shopping malls, or on packed public transport.

fondling the victim’s genitals, buttocks, or breasts, or rubbing the penis vigorously against the victim until orgasm occurs. Observations like these encouraged Langevin (1983) to view frotteurism as a form of sexual aggression belonging to the same category as rape/sexual assault.

Question 98

Pedophillic disorder

Answer 98

ndividuals who exhibit a predominant sexual interest in, or preference toward, prepubescent children (Freund, 1981; Marshall, 1997). Specifically, this paraphilia is characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child (generally defined as aged 13 years or younger in the DSM-5-TR;

Question 99

Child molestor

Answer 99

is an individual who has engaged in a sexually motivated act against a prepubescent child, without an indication of preference,

Question 100

Pedophile

Answer 100

is an individual who has displayed a preference for sexual behaviour with a child

Question 101

Sexual assault

Answer 101

Sexual assault refers to the many ways in which a person can be violated. Historically, the only sexual assault considered was rape. The term rape, in its traditional sense, refers to forced penetration of an unwilling female’s vagina by a male assailant’s penis. Not only did this definition exclude the sexual assault of males, it placed quite unnecessary emphasis on penile–vaginal intercourse. In terms of legal processes, this requirement of demonstrated forced vaginal intercourse in order to obtain a conviction of rape caused so many problems that Canadian legislators decided to change the law

Question 102

Others

Answer 102

Sexual satisfaction derived from receiving enemas (klismaphilia), as well as urination (urophilia) or defecation (coprophilia), occurs frequently enough that pornographers cater to such interests. Some less frequent paraphilias, however, involve activities that break the law, such as sex with animals (zoophilia or bestiality), or that take the form of obscene telephone calls (scatologia)

Question 103

Conditioning theories

Answer 103

A young man, for example, might be caught in the act of masturbating by an attractive woman, and this association between high sexual arousal and a woman seeing his exposed penis might, according to this conditioning account, serve to entrench an attraction to (or preference for) exposing his penis to women. Similar accidental associations between sexual arousal and seeing younger children were said to be the conditioning bases of future child molestation, while masturbating to pornographic images of, or to thoughts of, sexually assaulting a woman were said to instill a preference for rape.

Question 104

Neurodevelopment theories

Answer 104

Non-right-handedness and minor physical anomalies are signs of neurodevelopmental problems in utero, and in support of a neurodevelopmental hypothesis, non-right-handedness was found more frequently in pedophiles (Cantor et al., 2004), as were minor physical anomalies (Dyshniku et al., 2015). Pedophiles were also more likely to have head injuries before, but not after, the age of 13 years (Blanchard et al., 2002). Findings from numerous studies also show that pedophiles have lower IQs than non-pedophile offenders, and they are more likely to have repeated school grades or received special education

Question 105

Childhood and social development theories

Answer 105

Sexual offenders do typically have disrupted childhoods, and there is clear evidence that such experiences leave a child feeling unlovable, lacking in self-confidence, with poor social skills, and with a propensity for antisocial behaviour (Loeber, 1990). In this theory, however, it is not just poor parenting that produces sexual offending; socio-cultural factors, accidental opportunities, and transitory states all contribute to the complex array of influences that set the stage for sexual offending.

Question 106

Medical Interventions

Answer 106

The aim of medical interventions is to eliminate or to reduce sexual drive so the person will be uninterested in sex or will easily be able to control the expression of paraphilic interests. Physical castration, the surgical removal of the testicles, essentially eliminates the body’s production of testosterone, the sex steroid that plays a role in sexual drive. The relationship between testosterone and sexual aggression is well established (Bradford, 2000). Castration is associated with lower recidivism rates in offenders

Question 107

Anti-androgens reduce

Answer 107

sexual interest, fantasies, and behaviours in sexual offenders (Rösler & Witztum, 2000), though side effects are considerable.

Question 108

Other treatments

Answer 108

selective serotonin reuptake inhibitors (SSRIs) and luteinizing hormone-releasing hormone (LHRH) agonists. Both medications have demonstrated an ability to reduce or allvliate sexual fantasy, urges, and behaviours (Briken, Nika, & Berner, 2001; Fedoroff, 1993; Rösler & Witztum, 1998) without causing significant side effects.