Sexual Dysfunctions Paraphilias Gender Identity Disorders

1. Abnormal PsychologyOltmanns and EmeryChapter TwelveSexual and Gender Identity Disorders presented by:Mani Rafiee

2. Chapter Outline • Sexual Dysfunctions • Paraphilias • Gender Identity Disorders

3. Overview • Any discussion of sexual disorders requires some frank consideration of normal sexuality. • William Masters, a physician, and Virginia Johnson, a psychologist, were undoubtedly the best-known sex therapists and researchers in the United States during the second half of the twentieth century.

4. Overview • Masters and Johnson described the human sexual response cycle in terms of a sequence of overlapping phases: excitement, orgasm, and resolution. • Sexual excitement increases continuously from initial stimulation up to the point of orgasm. • Among the most dramatic physiological changes during sexual excitement are those associated with vasocongestion—engorgement of the blood vessels of various organs, especially the genitals.

5. Overview • The experience of orgasmis usually distinct from the gradual buildup of sexual excitement that precedes it. • This sudden release of tension is almost always experienced as being intensely pleasurable, but the specific nature of the experience varies from one person to the next.

6. Overview • The female orgasm occurs in three stages, beginning with a “sensation of suspension or stoppage,” which is associated with strong genital sensations. • The second stage involves a feeling of warmth spreading throughout the pelvic area. • The third stage is characterized by sensations of throbbing or pulsating, which are tied to rhythmic contractions of the vagina, the uterus, and the rectal sphincter muscle.

7. Overview • The male orgasm occurs in two stages, beginning with a sensation of ejaculatory inevitability. • This is triggered by the movement of seminal fluid toward the urethra. • In the second stage, regular contractions propel semen through the urethra, and it is expelled through the urinary opening.

8. Overview • During the resolution phase, which may last 30 minutes or longer, the person’s body returns to its resting state. • Men are typically unresponsive to further sexual stimulation for a variable period of time after reaching orgasm. • This is known as the refractory period. • Women, on the other hand, may be able to respond to further stimulation almost immediately.

9. Overview • Sexual dysfunctions can involve a disruption of any stage of the sexual response cycle. • Many sexual problems are best defined in terms of the couple rather than each partner individually. • Although problems in sexual behavior clearly involve basic physiological responses and behavioral skills, each person’s thoughts about the meaning of sexual behavior are also extremely important.

10. Overview Brief Historical Perspective • Early medical and scientific approaches to sexual behavior were heavily influenced by religious doctrines and prevailing cultural values. • The exclusive purpose of sexual behavior was assumed to be biological reproduction; anything that varied from that narrow goal was considered a form of psychopathology and was usually subject to severe moral and legal sanctions.

11. Overview Brief Historical Perspective (continued) • The period between 1890 and 1930 saw many crucial changes in the ways in which society viewed sexual behavior. • A significant number of people were beginning to think of sex as something other than a simple procreative function. • If the purpose of sexual behavior was to foster marital intimacy or to provide pleasure, then interference with that goal might become a legitimate topic of psychological inquiry.

12. Overview Brief Historical Perspective (continued) • Changes in prevailing social attitudes led to a change in the focus of systems for the classification of sexual problems. • Over the course of the later twentieth century and into the twenty-first, there has been a trend toward greater tolerance of sexual variation among consenting adult partners and toward increased concern about impairments in sexual performance and experience.

13. Overview Brief Historical Perspective (continued) • Several leading intellectuals influenced public and professional opinions regarding sexual behavior during the first half of the twentieth century. • The work of Alfred Kinsey, a biologist at Indiana University, was especially significant. • In keeping with his conscious adherence to scientific methods, Kinsey adopted a behavioral stance, focusing specifically on those experiences that resulted in orgasm.

14. Overview Brief Historical Perspective (continued) • The incredible diversity of experiences reported by Kinsey’s subjects led him to reject the distinction between normal and abnormal sexual behavior. • He argued that differences among people are quantitative rather than qualitative. • For example, Kinsey suggested that the distinction between heterosexual and homosexual persons was essentially arbitrary and fundamentally meaningless.

15. Sexual Dysfunctions • Inhibitions of sexual desire and interference with the physiological responses leading to orgasm are called sexual dysfunctions. • Problems can arise anywhere, from the earliest stages of interest and desire through the climactic release of orgasm.

16. Sexual Dysfunctions Symptoms • The most comprehensive information that is available regarding normal sexual behavior and satisfaction was collected by the National Health and Social Life Survey (NHSLS), the first large-scale follow-up to the Kinsey reports. • Their questionnaire asked about masturbation and four basic sexual techniques involving partners: vaginal intercourse, fellatio, cunnilingus, and anal intercourse.

17. Sexual Dysfunctions Symptoms (continued) • The results indicate that masturbation is relatively common among both men and women. Virtually all of the men (95 percent) and women (97 percent) had experienced vaginal intercourse at some time during their lives. • The investigators concluded that the vast majority of heterosexual encounters focus on vaginal intercourse.

18. Sexual Dysfunctions Symptoms (continued) • Most of the men (75 percent) and women (65 percent) also reported that they had engaged in oral sexual activities (as both the person giving and receiving oral-genital stimulation). • Relatively few men (25 percent) and women (20 percent) reported that they had ever engaged in anal intercourse. • Most sexual activity occurs in the context of monogamous relationships.

19. Sexual Dysfunctions Symptoms (continued) • NHSLS results include the ways in which the participants described the quality of their experiences during sexual activity. • Only 29 percent of women reported that they always have an orgasm with a specific partner, compared to 75 percent of men. • Second, 44 percent of men reported that their partners always had orgasms during sex. • This figure is much higher than the rate reported by women themselves.

20. Sexual Dysfunctions Symptoms (continued) • A large proportion of both men and women indicated that they were extremely satisfied with their partners, on both the physical and emotional dimensions. • Strong negative emotions, such as anger, fear, and resentment, are often associated with sexual dissatisfaction. • In some cases, these emotional states appear before the onset of the sexual problem, and sometimes they develop later.

21. Sexual Dysfunctions Diagnosis • DSM-IV-TR subdivides sexual dysfunctions into several types. • For many types of disorder, the clinician must decide whether the person has engaged in sexual activities that would normally be expected to produce sexual arousal or orgasm.

23. Sexual Dysfunctions Diagnosis (continued) • One diagnostic criterion that is required for all forms of sexual dysfunction defined in DSMIV- TR is the demonstration that the problem in question leads to marked distress or interpersonal difficulty.

24. Sexual Dysfunctions Hypoactive Sexual Desire Disorder • Inhibited, or hypoactive, sexual desire is defined in terms of subjective experiences, such as lack of sexual fantasies and lack of interest in sexual experiences. • The absence of interest in sex must be both persistent and pervasive to be considered a clinical problem. • The absolute frequency with which a person engages in sex cannot be used as a measure of inhibited sexual desire because the central issue is interest—actively seeking out sexual experiences—rather than participation.

25. Sexual Dysfunctions Hypoactive Sexual Desire Disorder (continued) • The fact that hypoactive sexual desire is listed in DSM-IV-TR as a type of disorder should not lead us to believe that it is a unitary condition with a simple explanation. • It is, in fact, a collection of many different kinds of problems. • People who suffer from low levels of sexual desire frequently experience other mental and medical disorders.

26. Sexual Dysfunctions Sexual Aversion Disorder • Some people develop an active aversion to sexual stimuli and begin to avoid sexual situations altogether. • Some people avoid only certain aspects of sexual behavior, such as kissing, intercourse, or oral sex. • This reaction is stronger than a simple lack of interest.

27. Sexual Dysfunctions Sexual Aversion Disorder (continued) • Fear of sexual encounters can occasionally reach intense proportions, at which point it may be better characterized as sexual aversion disorder. • This problem might be viewed as a kind of phobia because it extends well beyond anxiety about sexual performance.

28. Sexual Dysfunctions Male Erectile Disorder • Many men experience difficulties either in obtaining an erection that is sufficient to accomplish intercourse or maintaining an erection long enough to satisfy themselves and their partners during intercourse. • Both problems are examples of erectile dysfunction. • Men with this problem may report feeling subjectively aroused, but the vascular reflex mechanism fails, and sufficient blood is not pumped to the penis to make it erect.

29. Sexual Dysfunctions Male Erectile Disorder (continued) • This phenomenon used to be called impotence, but the term has been dropped because of its negative implications. • Erectile dysfunctions can be relatively transient, or they can be more chronic.

30. Sexual Dysfunctions Female Sexual Arousal Disorder • A woman is said to experience inhibited sexual arousal if she cannot either achieve or maintain genital responses, such as lubrication and swelling that are necessary to complete sexual intercourse. • The desire is there, but the physiological responses that characterize sexual excitement are inhibited.

31. Sexual Dysfunctions Premature Ejaculation • Many men experience problems with the control of ejaculation. • They are unable to prolong the period of sexual excitement long enough to complete intercourse. This problem is known as premature ejaculation. • Once they become intensely sexually aroused, they reach orgasm very quickly.

32. Sexual Dysfunctions Female Orgasmic Disorder • Women who experience orgasmic difficulties may have a strong desire to engage in sexual relations, they may find great pleasure in sexual foreplay, and they may show all the signs of sexual arousal. • Nevertheless, they cannot reach the peak erotic experience of orgasm. • Women whose orgasmic impairment is generalizedhave never experienced orgasm by any means. • Situationalorgasmic difficulties occur when the woman is able to reach orgasm in some situations but not in others.

33. Sexual Dysfunctions Orgasmic Disorder • Orgasmic disorder in women is somewhat difficult to define in relation to inhibited sexual arousal because the various components of female sexual response are more difficult to measure than are erection and ejaculation in the male. • Women with this disorder report that when engaging in intercourse they do not have difficulty lubricating and experience no pain.

34. Sexual Dysfunctions Orgasmic Disorder (continued) • However, they report no genital sensations (hence the term genital anesthesia) and do not appear to know what sexual arousal is. • Most of these women seek therapy because they have heard from others or have read that they are missing something, rather than because they themselves feel frustrated.

35. Sexual Dysfunctions Pain During Sex • Some people experience persistent genital pain during or after sexual intercourse, which is known as dyspareunia. • The problem can occur in either men or women, although it is considered to be much more common in women. • Some women find that whenever penetration of the vagina is attempted, the muscles around the entrance to the vagina snap tightly shut, preventing insertion of any object.

36. Sexual Dysfunctions Pain During Sex (continued) • This involuntary muscular spasm, known as vaginismus, prevents sexual intercourse as well as other activities, such as vaginal examinations and the insertion of tampons. • Many women experience genital pain during sexual stimulation other than intercourse.

37. Sexual Dysfunctions Sexual Addiction: A Proposal • DSM-IV-TR includes unusually low sexual desire as a sexual dysfunction, but it does not mention unusually high sexual desire. • In contrast, ICD-10 does include a category called excessive sexual drive. • Symptoms associated with this condition presumably include such behaviors as seeking new sexual encounters out of boredom with old ones, frequent use of pornography, and legal problems resulting from sexual behaviors.

38. Sexual Dysfunctions Sexual Addiction: A Proposal (continued) • Additional features include obsessive thoughts about sexual encounters, guilt resulting from problematic sexual behavior, and rationalization for continued reckless sexual behavior.

39. Sexual Dysfunctions in DSM 5 • Genito-pelvic pain/penetration disorder is new in DSM-5 and represents a merging of the DSM-IV categories of vaginism and dyspareunia, • for females, sexual desire and arousal disorders have been combined into one disorder: female sexual interest/arousal disorder.

40. Sexual Dysfunctions Frequency • Surveys conducted among the general population indicate that some forms of sexual dysfunction are relatively common. • The most extensive set of information regarding sexual problems among people living in the community comes from the National Health and Social Life Survey (NHSLS).

41. Sexual Dysfunctions Frequency (continued) • According to this study, premature ejaculation is the most frequent form of male sexual dysfunction, affecting almost one out of every three adult men. • All the other forms of sexual dysfunction are reported more often by women. • One-third of women said that they lacked interest in sex, and almost one-quarter indicated that they experienced a period of several months during which they were unable to reach orgasm.

43. Sexual Dysfunctions Sexual Behavior Across the Life Span • Studies indicate that many people remain sexually active later in life. • Gender differences become marked in the late fifties, when rates of inactivity increase dramatically for women. • Differences between younger and older people are mostly a matter of degree.

44. Sexual Dysfunctions Sexual Behavior Across the Life Span (continued) • The prevalence of certain types of sexual dysfunction increases among the elderly, particularly among men. • The relation between sexual experience and aging is closely related to other health problems that increase with age. • People who rate their health as being excellent have many fewer sexual problems than people who rate their health as being only fair or poor.

45. Sexual Dysfunctions Cross-Cultural Comparisons • Patients with sexual disorders seek treatment at clinics all over the world. • Therefore, these problems are not unique to any particular culture. • Cultural and ethnic differences have been reported for sexual practices, beliefs about sexuality, and patterns of sexual decision making.

46. Sexual Dysfunctions Cross-Cultural Comparisons • It is not clear whether variations in sexual behavior are accompanied by cultural differences in the frequency and form of sexual dysfunctions. • Cross-cultural studies of prevalence rates for specific sexual dysfunctions have not been reported.

47. Sexual Dysfunctions Causes • The experience of sexual desire is partly controlled by biological factors. • Sexual desire is influenced by sex hormones for both men and women. • In males, sexual appetite is impaired if the level of testosterone falls below a particular point (close to the bottom of the laboratory normal range), but above that threshold, fluctuations in testosterone levels will not be associated with changes in sexual desire.

48. Sexual Dysfunctions Causes (continued) • The reduction of male sex hormones over the life span probably explains, at least in part, the apparent decline in sexual desire among elderly males. • Many cases of erectile dysfunction can be attributed to vascular, neurological, or hormonal impairment. • Various kinds of drugs can also influence a man’s erectile response.

49. Sexual Dysfunctions Causes (continued) • A number of biological factors and physiological diseases can impair a woman’s ability to become sexually aroused. • Various types of neurological disorder, pelvic disease, and hormonal dysfunction can interfere with the process of vaginal swelling and lubrication. • Inhibited orgasm, in both men and women, is sometimes caused by the abuse of alcohol and other drugs.

50. Sexual Dysfunctions Causes (continued) • Although sexual desire is rooted in a strong biological foundation, psychological variables also play an important role in the determination of which stimuli a person will find arousing. • Sexual desire and arousal are determined, in part, by mental scripts that we learn throughout childhood and adolescence.