Week 6 Lecture 6 - Sexual Dysfunctions, Paraphilias, & Gender Dysphoria - Jo Fielding (DN) Flashcards Preview

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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 




What are the 3 disorders of Interest, Desire & Arousal?


  • Male hypoactive sexual desire disorder
  • Erectile disorder



  • Female sexual interest/arousal disorder


What are the 3 Orgasmic Disorders?


  • Delayed ejaculation
  • Premature (early) ejaculation



  • 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 +




How do we define premature?

ejaculating within

1.8 min (people generally complain)

7.3 min (no complaints!!!)


Key features of Delayed Ejaculation?

Persistent delay, infrequency or absence or orgasm

75% of occasions




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




What are the DSM specifiers used to designate the onset of  Sexual Dysfunction?


present from first sexual experience



develop after period of relatively normal sexual function



not limited to certain types of stimulation, situation, partner



only with certain types of stimulation, situation, partner




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:

  • 1. Symptoms must have persisted for a minimum duration of 6 months
  • 2. Symptoms must cause clinically significant distress
  • 3. 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




Female Sexual Interest /Arousal Disorder

A dysfunction of sexual interest, desire & arousal

Diminished, absent, or reduced frequency of at least 3 of the following :

  • 1. Interest in sexual activity
  • 2. Sexual/erotic thoughts or fantasies
  • 3. Initiation of sexual activity & responsiveness to partner’s attempts to initiate
    • Beliefs & preferences highly relevant
  • 4. Sexual excitement/pleasure - ≥75% of sexual encounters
  • 5. Sexual interest/arousal elicited by any internal or external erotic cues
    • Adequacy of sexual stimuli?
  • 6. Genital or nongenital sensations - ≥75% of sexual encounters




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




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




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




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:
    • 1. Symptoms developed during or soon after intoxication or withdrawal
    • 2. 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




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




Psychological factors contributing to sexual dysfunction?

  • Negative expectancies
    • Attentional focus on not performing
  • Increased autonomic arousal
  • Dysfunctional performance
  • Avoidance behaviours




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?



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
  • 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