Sexual Disorders and Gender Identity Disorder

Sexual Dysfunctions

n   Sexual dysfunctions are disorders in which people cannot respond normally in key areas of sexual functioning

n   As many as 31% of men and 43% of women in the U.S. suffer from such a dysfunction during their lives

n   Sexual dysfunctions are typically very distressing, and often lead to sexual frustration, guilt, loss of self-esteem, and interpersonal problems

n   The human sexual response can be described as a cycle with four phases:

n   Desire

n   Excitement

n   Orgasm

n   Resolution

n   Sexual dysfunctions affect one or more of the first three phases

Disorders of Desire

n   Desire phase of the sexual response cycle

n   Consists of an urge to have sex, sexual fantasies, and sexual attraction to others

n   Two dysfunctions affect this phase:

n   Hypoactive sexual desire disorder

n   Sexual aversion disorder

n   Hypoactive sexual desire disorder

n   Characterized by a lack of interest in sex and a low level of sexual activity

n   Physical responses may be normal

n   Prevalent in about 16% of men and 33% of women

n   DSM criteria refers to “deficient” sexual interest/activity but provides no definition of “deficient”

n   In reality, this criterion is difficult to define

n   Sexual aversion disorder

n   Characterized by a total aversion to (disgust of) sex

n   Sexual advances may sicken, repulse, or frighten

n   This disorder seems to be rare in men and more common in women

n   Biological causes

n   A number of hormones interact to produce sexual desire and behavior

n   Abnormalities in their activity can lower sex drive

n   These hormones include prolactin, testosterone, and estrogen for both men and women

n   Sex drive can also be lowered by chronic illness, some medications, some psychotropic drugs, and a number of illegal drugs

n   Sociocultural causes

n   Attitudes, fears, and psychological disorders that contribute to sexual desire disorders occur within a social context

n   Many sufferers of desire disorders are feeling situational pressures

nExamples: divorce, death, job stress, infertility, and/or relationship difficulties

n   Cultural standards can also impact the development of these disorders

n   The trauma of sexual molestation or assault is also likely to produce sexual dysfunction

Disorders of Excitement

n   Excitement phase of the sexual response cycle

n   Marked by changes in the pelvic region, general physical arousal, and increases in heart rate, muscle tension, blood pressure, and rate of breathing

n   In men: erection of the penis

n   In women: clitoral swelling and vaginal lubrication

n   Two dysfunctions affect this phase:

n   Female sexual arousal disorder (formerly “frigidity”)

n   Male erectile disorder (formerly “impotence”)

n   Female sexual arousal disorder

n   Characterized by repeated inability to maintain proper lubrication or genital swelling during sexual activity

n   Many with this disorder also have desire or orgasmic disorders

n   It is estimated that more than 10% of women experience this disorder

n   Because this disorder is so often tied to an orgasmic disorder, researchers usually study the two together; causes of the two disorders will be discussed together

n   Male erectile disorder (ED)

n   Characterized by repeated inability to attain or maintain an adequate erection during sexual activity

n   An estimated 10% of men experience this disorder

n   Most are over the age of 50 years

n   Many cases are associated with medical ailments or disease

n   According to surveys, half of all adult men have erectile difficulty during intercourse at least some of the time

n   Biological causes

n   The same hormonal imbalances that can cause hypoactive sexual desire can also produce ED

n   Most commonly, vascular problems are involved

n   ED can also be caused by damage to the nervous system from various diseases, disorders or injuries

n   The use of certain medications and substances may interfere with erections

n   Psychological factors

n   Any of the psychological causes of hypoactive sexual desire can also interfere with erectile function

n   For example, as many as 90% of men with severe depression experience some degree of ED

n   One well-supported cognitive explanation for ED emphasizes performance anxiety and the spectator role

n   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

nThis can create a vicious cycle of sexual dysfunction where the original cause of the erectile failure becomes less important that the fear of failure

Disorders of Orgasm

n   Premature ejaculation

n   Characterized by persistent reaching of orgasm and ejaculation with little sexual stimulation

n   About 30% of men experience premature ejaculation at some time

n   Psychological, particularly behavioral, explanations of this disorder have received more research support than other theories

n   The dysfunction seems to be typical of young, sexually inexperienced men

n   It may also be related to anxiety, hurried masturbation experiences, or poor recognition of arousal

n   Male orgasmic disorder

n   Characterized by a repeated inability to reach orgasm or by a very delayed orgasm after normal sexual excitement

n   Occurs in 8% of the male population

n   Biological causes include low testosterone, neurological disease, and head or spinal injury

n   Medications, including certain antidepressants (especially SSRIs) and drugs that slow down the CNS, can also affect ejaculation

n   A leading psychological cause appears to be performance anxiety and the spectator role, the cognitive factors involved in ED

n   Female orgasmic disorder

n   Characterized by persistent delay in or absence of orgasm following normal sexual excitement

n   Almost 25% of women appear to have this problem

n10% or more have never reached orgasm
nAn additional 10% reach orgasm only rarely

n   Women who are more sexually assertive and more comfortable with masturbation tend to have orgasms more regularly

n   Female orgasmic disorder appears more common in single women than in married or cohabiting women

n    Most clinicians agree that orgasm during intercourse is not mandatory for normal sexual functioning

n   Early psychoanalytic theory used to consider lack of orgasm during intercourse to be pathological

n    Typically linked to female sexual arousal disorder

n   The two disorders tend to be studied and treated together

n    Once again, biological, psychological, and sociocultural factors may combine to produce these disorders

n   Psychological causes

n   The psychological causes of hypoactive sexual desire and sexual aversion may also lead to female arousal and orgasmic disorders

n   Memories of childhood trauma and relationship distress may also be related

n   Sociocultural causes

n   For decades, the leading sociocultural theory of female sexual dysfunction was that it resulted from sexually restrictive cultural messages

n   This theory has been challenged because:
nSexually restrictive histories are equally common in women with and without disorder
nCultural messages about female sexuality have been changing while the rate of female sexual dysfunction stays constant

Disorders of Sexual Pain

n   Vaginismus

n   Characterized by involuntary contractions of the muscles of the outer third of the vagina

n   Severe cases can prevent a woman from having intercourse

n   Perhaps 20% of women occasionally have pain during intercourse, but less than 1% of all women have vaginismus

n    Most clinicians agree with the cognitive-behavioral theory that vaginismus is a learned fear response

n   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

n    Some women experience painful intercourse because of infection or disease, leading to “rational” vaginismus

n    Most women with vaginismus also have other sexual disorders

n    Dyspareunia

n    Characterized by severe pain in the genitals during sexual activity

n   Surveys suggest that 14% of women and 3% of men are affected

n    Dyspareunia in women usually has a physical cause, most commonly from injury sustained in childbirth

n    Although relationship problems or psychological trauma from abuse may contribute to dyspareunia, psychosocial factors alone rarely are responsible

Treatments for Sexual Dysfunctions

n   The last 35 years have brought major changes in the treatment of sexual dysfunction

n   Early 20th century: psychodynamic therapy

n   Believed that sexual dysfunction was caused by failure to negotiate the stages of psychosexual development

n   Therapy focused on gaining insight and making broad personality changes and generally was unhelpful

n   1950s and 1960s: behavioral therapy

n   Attempted to reduce fear by applying relaxation training and systematic desensitization

n   Had moderate success, but failed to work in cases where the key problems were cognitive or psychoeducational

What Are the General Features of Sex Therapy?

n    Modern sex therapy includes:

n    Assessing and conceptualizing the problem

n    Assigning “mutual responsibility” for the problem

n    Education about sexuality

n    Attitude change

n    Elimination of performance anxiety and the spectator role

n    Increasing sexual and general communication skills

n    Changing destructive lifestyles and marital interactions

n    Addressing physical and medical factors

What Techniques Are Applied to Particular Dysfunctions?

n    Erectile disorder

n    Treatments for ED focus on reducing a man’s performance anxiety and/or increasing his stimulation

n   May include sensate-focus exercises such as the “tease technique”

n    Biological approaches, used when ED has biological causes, have gained great momentum with the recent approval of sildenafil (Viagra)

n   Most other biological approaches have been around for decades and include gels, suppositories, penile injections, a vacuum erection device (VED), and penile implant surgery

n    Premature ejaculation

n    Premature ejaculation has been successfully treated for years by behavioral procedures such as the “stop-start” or “pause” technique

n    Some clinicians favor the use of fluoxetine (Prozac) and other serotonin-enhancing antidepressant drugs

n   Because these drugs often reduce sexual arousal or orgasm, they may be helpful in delaying premature ejaculation

n   While some studies have reported positive findings, long-term outcome studies have yet to be conducted

n    Vaginismus

n    Specific treatment for vaginismus takes two approaches:

n   Practice tightening and releasing the muscles of the vagina to gain more voluntary control

n   Overcome fear of intercourse through gradual behavioral exposure treatment

n    Over 75% of women treated for vaginismus using these methods eventually reported pain-free intercourse


n   According to the DSM-IV, paraphilias should be diagnosed only when the urges, fantasies, or behaviors last at least 6 months

n   For most paraphilias, the urges, fantasies, or behaviors must also cause great distress or impairment

n   For certain paraphilias, however, performance of the behavior itself is indicative of a disorder

n   Example: sexual contact with children


n   The key features of fetishism are recurrent intense sexual urges, sexually arousing fantasies, or behaviors that involve the use of a nonliving object

n   The disorder usually begins in adolescence

n   Almost anything can be a fetish

n   Women’s underwear, shoes, and boots are especially common

n    Behaviorists propose that fetishes are learned through classical conditioning

n    Fetishes are sometimes treated with aversion therapy, covert sensitization, or imaginal exposure

n    Another behavioral treatment is masturbatory satiation, in which clients masturbate to boredom while imagining the fetish object

n    An additional behavioral treatment is orgasmic reorientation, a process which teaches individuals to respond to more appropriate sources of sexual stimulation

Transvestic Fetishism

n    The typical person with transvestism is a heterosexual male who began cross-dressing in childhood or adolescence

n    Transvestism is often confused with gender identity disorder (transsexualism), but the two are separate patterns

n    The development of the disorder seems to follow the behavioral principles of operant conditioning


n    Characterized by arousal from the exposure of genitals in a public setting

n   Sexual contact is neither initiated nor desired

n    Usually begins before age 18

n    Treatment generally includes aversion therapy and masturbatory satiation

n   May be combined with orgasmic reorientation, social skills training, or psychodynamic therapy


n    A person who develops frotteurism has fantasies, urges, or behaviors involving touching and rubbing against a nonconsenting person

n    Almost always male, the person fantasizes during the act that he is having a caring relationship with the victim

n    Usually begins in the teenage years or earlier

n    Acts generally decrease and disappear after age 25


n    Characterized by fantasies, urges, or behaviors involving sexual activity with a prepubescent child, usually 13 years of age or younger

n    Some people are satisfied with child pornography

n    Others are driven to watch, fondle, or engage in intercourse with children

n    Victims may be male, but evidence suggests that two-thirds are female

A Word of Caution

n   The definitions of paraphilias, like those of sexual dysfunctions, are strongly influenced by the norms of the particular society in which they occur

n   Some clinicians argue that, except when people are hurt by them, paraphilic behaviors should not be considered disorders at all

Gender Identity Disorder

n   Gender identity disorder, or transsexualism, is one of the most fascinating disorders related to sexuality

n   People with this disorder persistently feel that they have been assigned to the wrong biological sex

n   They would like to remove their secondary sex characteristics and acquire the characteristics of the opposite sex

n    People with gender identity disorder usually feel uncomfortable wearing the clothes of their own sex and may cross-dress

n    This is distinctly different than a transsexual fetish; there is no sexual arousal related to this behavior

n    The disorder sometimes emerges in childhood and disappears with adolescence

n    In some cases it develops into adult gender identity disorder