Sex Disorders

Sexual Dysfunctions Gender Identity Disorder Paraphilias

Pedophilia

Compulsive Sexual Behavior (not in the DSM) Rape (where does this fit in scheme?)

Sexual Dysfunctions
Disturbance in the processes that characterize the sexual response cycle Or Pain associated with sexual intercourse

The Sexual Response Cycle

From Masters & Johnson, 1966 1. Desire 2. Arousal 3. Plateau* 4. Orgasm 5. Resolution* * No diagnosable disorders associated with these phases

Sexual Desire Disorders

Hypoactive Sexual Desire Disorder
Deficient or absent sexual fantasies and desire for sexual activity

Sexual Aversion Disorder

Extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner

Sexual Arousal Disorders

Male Female Male Erectile Disorder Female Sexual Arousal Disorder Inability to attain, or
maintain until completion of sexual activity, an adequate erection Inability to attain, or maintain until completion of sexual activity, adequate lubrication-swelling response

Orgasmic Disorders
Male Male Orgasmic Disorder
Delay in, or absence of, orgasm following normal sexual excitement.

Female Female Orgasmic Disorder

Delay in, or absence of, orgasm following normal sexual excitement. Orgasmic capacity is less than would be reasonable for age, experience, and adequacy of stimulation

Premature Ejaculation
Ejaculation w/ minimal stimulation before the person wishes it

Sexual Pain Disorders

Male Dyspareunia
Genital pain associated with sexual intercourse

Female Dyspareunia
Genital pain associated with sexual intercourse

Vaginismus
Involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse

Sexual Dysfunctions - Subtypes

Onset
Lifelong Type Acquired Type

Context
Generalized Type Situational Type

Etiology
Due to Psychological Factors Due to Combined Factors

Gender Identity Disorder

A. Strong & persistent cross-gender identification In children, manifested by 4 (or more) symptoms, including insistence that he or she is the opposite sex, preference for cross-sex roles and activities, and preference for opposite sex playmates. In adolescents & adults, symptoms include stated desire to be other sex, frequent passing as other sex, desire to live as other sex, or conviction that he or she has typical feeling of other sex

Gender Identity Disorder

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex (often includes desire to be rid of primary and secondary sex characteristics) C. Not concurrent with a physical intersex condition D. Distress or impairment

G.I.D. vs. Homosexuality

Homosexuality is not a disorder (used to be, but not anymore) Gender Identity Disorder is independent of sexual orientation (e.g. a genetic male can want to be a woman and still be attracted to women) Big rate difference: G.I.D. approx 1/30,000 men, 1/100,000 women. Homosexuality: approx 3% population, gender ratio 2:1 male:female

G.I.D. vs. Transvestic Fetishism

In transvestites, there is usually no desire to switch gender (if there is, its diagnosed With Gender Dysphoria), but crossdressing done for sexual gratification or sense of well-being Transvestic Fetishism diagnosed only in heterosexual males

Paraphilias
Exhibitionism Fetishism Frotteurism Pedophilia Sexual Masochism Sexual Sadism Transvestic Fetishism Voyeurism Paraphilia NOS

Pedophilia
A. Over at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children (generally < 13 years old) B. The person has acted on these urges, or urges or fantasies cause distress or interpersonal difficulty C. The person is at least age 16 years and at least 5 years older than the children in Criterion A

Pedophilia
Specify if
Sexually attracted to males Sexually attracted to females Sexually attracted to both

Specify if
Limited to incest

Specify type
Exclusive type Nonexclusive type

Pedophilia
Not the same thing as child molestation
Pedophiles may not act on their urges Child molesters may not have pedophilic arousal patterns

Pedophilic arousal patterns are fairly strong predictors of recidivism

Pedophilia - Assessment
Phallometric assessment penile plethesmography (uses penile strain gage or measure of blood volume) Arousal assessed while viewing slides of nude children and adults (often includes audio narrative) Arousal to child slides compared to arousal to adult slides

Compulsive Sexual Behavior

Not a DSM diagnosis (maybe Sexual Disorder, N.O.S.) Includes elements of:
Sexual addiction Nymphomania/Satryriasis Hypersexuality

Can be paraphilic or nonparaphilic

Compulsive Sexual Behavior

Essentially, nonparaphilic CSB involves conventional and normative sexual behavior taken to a compulsive extreme. There is no clear category for this type of clinical syndrome - of obsessive and compulsive normophilic behavior.

CSB Proposed Criteria

Coleman, et al., 2000 A) Recurrent and intense normophilic sexually arousing fantasies, sexual urges, and behaviors which cause clinically significant distress in social, occupational, or other important areas of functioning.

CSB Criteria contd

B) Not due to a another medical condition, substance use disorder, attributable to another Axis I or II disorder, developmental disorder, and must take into account norms of gender, sexual orientation and sociocultural groups.

Types of Nonparaphilic CSB

Compulsive cruising and multiple partners Compulsive fixation on an unattainable partner Compulsive autoeroticism Compulsive multiple love relationships Compulsive sexuality in a relationship Possibly: Compulsive Use of Erotica Compulsive Use of the Internet for Sexual Purposes

CSB - Etiology
No agreement on this, thought of as: Variant of OCD Impulse Control Disorder Disorder of sexual desire Etc. Disagreement may be due to multiple types, possibly on a continuum

CSB-The Continuum Notion

Healthy

Problematic Impulsive

Clinical Syndrome Compulsive

Other Axis I Psychopathologies Axis II: Characteriolgical

CSB Associated Problems

Tend to have comorbid mood disorders (dysthymia or depression) or undiagnosed dysphoric mood A large number have problems with impulsivity, notably substance abuse and risky sexual behavior

What about Rape?

What motivates rape?
Most rapists dont have deviant sexual arousal
Plethesmography does not assess appetitive behavior frequency or intensity but does assess the objective of arousal Though deviant arousal plus high PCLR score best indicator of recidivism

Some rapists have comorbid paraphilias Is rape sexually motivated ?

From Kafka

Rape
From The Multidimensional Assessment of Sex and Aggression (MASA; Knight, 1994; 1999) Sexually coercive men were statistically significantly more likely to self-report more sexual fantasy and enacted sexual behavior in multivariate statistics (p= < 0.01) Differences were most robust in:
ideal desired frequency of sexual behavior TSO/week in past 6 months Lifetime maximum TSO/week

Knight , 2002, submitted for publication

What Makes a Rapist?

Sadistic Pervasively Angry

Vindictive

Abusive Hx CU Impulsivity Hypersexual

Predicting Sexual Recidivism

No one really does it well Plenty of instruments (MnSOST-R, VRAG, RRASOR. . .) None are quite as effective as they say they are Problems with predicting low base rate events

Other Relevant Classes May Session 2005 (5/23-6/10) PSY 3960 the Psychology of the Sex Offender 2 credits MTWThF, 11:15 AM 1:35 PM Summer 2005 (6/13-8/5) PSY 3960 Law & Psychology 3 credits TTH, 6:20-8:50 PM (Also offered Spring 2006, schedule T.B.A.)