Chapter 13

Sexual Disorders and Gender Identity

Disorder

Slides & Handouts by Karen Clay Rhines, Ph.D.

Seton Hall University

Sexual Disorders and

Gender Identity Disorder
Sexual behavior is a major focus of both our private

thoughts and public discussions

Experts recognize two general categories of sexual

disorders:

Sexual dysfunctions problems with sexual responses

Paraphilias sexual urges and fantasies in response to
socially inappropriate objects or situations

The DSM also includes a diagnosis called gender

identity disorder, a sex-related disorder in which people

feel that they have been assigned to the wrong sex
Slide 2

Sexual Dysfunctions
Sexual dysfunctions are disorders in which people

cannot respond normally in key areas of sexual

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

Sexual dysfunctions are typically very distressing,

and often lead to sexual frustration, guilt, loss of

self-esteem, and interpersonal problems

Slide 3

Sexual Dysfunctions
The human sexual response can be described

as a cycle with four phases:

Desire
Excitement
Orgasm
Resolution

Sexual dysfunctions affect one or more of the

first three phases

Slide 4

Slide 5

Slide 6

Sexual Dysfunctions
Some people struggle with sexual dysfunction their

whole lives (labeled lifelong type in DSM-IV)

For others, normal sexual functioning preceded the
disorder (labeled acquired type)

In some cases the dysfunction is present during all

sexual situations (labeled generalized type)

In others it is tied to particular situations (labeled
situational type)

Slide 7

Disorders of Desire
Desire phase of the sexual response cycle
Consists of an urge to have sex, sexual fantasies,
and sexual attraction to others

Two dysfunctions affect this phase:

Hypoactive sexual desire disorder
Sexual aversion disorder

Slide 8

Disorders of Desire
Hypoactive sexual desire disorder
Characterized by a lack of interest in sex and a
low level of sexual activity
Physical responses may be normal

Prevalent in about 16% of men and 33% of

women
DSM refers to deficient sexual interest/activity
but provides no definition of deficient
In reality, this criterion is difficult to define
Slide 9

Disorders of Desire
Sexual aversion disorder
Characterized by a total aversion to (disgust of)
sex
Sexual advances may sicken, repulse, or frighten

This disorder seems to be rare in men and more

common in women

Slide 10

Disorders of Desire
A persons sex drive is determined by a

combination of biological, psychological, and

sociocultural factors, and any of these may
reduce sexual desire

Most cases of low sexual desire or sexual

aversion are caused primarily by sociocultural

and psychological factors, but biological
conditions can also lower sex drive
significantly
Slide 11

Disorders of Desire
Biological causes
A number of hormones interact to produce sexual
desire and behavior
Abnormalities in their activity can lower sex drive
These hormones include prolactin, testosterone, and
estrogen for both men and women

Sex drive can also be lowered by chronic illness,

some medications, some psychotropic drugs, and
a number of illegal drugs
Slide 12

Disorders of Desire
Psychological causes
A general increase in anxiety or anger may reduce
sexual desire in both women and men
Fears, attitudes, and memories may contribute to
sexual dysfunction
Certain psychological disorders, including
depression and obsessive-compulsive disorder,
may lead to sexual desire disorders
Slide 13

Disorders of Desire
Sociocultural causes
Attitudes, fears, and psychological disorders that
contribute to sexual desire disorders occur within a social
context
Many sufferers of desire disorders are feeling situational
pressures
Examples: divorce, death, job stress, infertility, and/or
relationship difficulties
Cultural standards can impact the development of these disorders
The trauma of sexual molestation or assault is also likely to
produce sexual dysfunction

Slide 14

Disorders of Excitement
Excitement phase of the sexual response cycle
Marked by changes in the pelvic region, general physical
arousal, and increases in heart rate, muscle tension, blood
pressure, and rate of breathing
In men: erection of the penis
In women: clitoral swelling and vaginal lubrication

Two dysfunctions affect this phase:

Female sexual arousal disorder (formerly frigidity)
Male erectile disorder (formerly impotence)
Slide 15

Disorders of Excitement
Female sexual arousal disorder
Characterized by repeated inability to maintain proper
lubrication or genital swelling during sexual activity
Many with this disorder also have desire or orgasmic disorders

It is estimated that more than 10% of women experience

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

Slide 16

Disorders of Excitement
Male erectile disorder (ED)
Characterized by repeated inability to attain or maintain
an adequate erection during sexual activity
An estimated 10% of men experience this disorder
Most are over the age of 50 years
Many cases are associated with medical ailments or disease

According to surveys, half of all adult men have erectile

difficulty during intercourse at least some of the time

Slide 17

Disorders of Excitement
Most cases of erectile disorder result from an

interaction of biological, psychological, and

sociocultural processes
Even minor physical impairment of the erection
response may make a man vulnerable to the
effects of psychosocial factors

Slide 18

Disorders of Excitement
Biological causes
The same hormonal imbalances that can cause
hypoactive sexual desire can also produce ED
Most commonly, vascular problems are involved
ED can also be caused by damage to the nervous
system from various diseases, disorders, or injuries

The use of certain medications and substances

may interfere with erections
Slide 19

Disorders of Excitement
Biological causes
Medical devices have been developed for
diagnosing biological causes of ED
One strategy involves measuring nocturnal penile
tumescence (NPT)
Men typically have erections during REM sleep; abnormal or
absent nighttime erections usually indicate a physical basis
for erectile failure

Slide 20

Disorders of Excitement
Psychological causes
Any of the psychological causes of hypoactive sexual desire
can also interfere with erectile function
For example, as many as 90% of men with severe depression
experience some degree of ED

One well-supported cognitive explanation for ED emphasizes

performance anxiety and the spectator role
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
This can create a vicious cycle of sexual dysfunction where the
original cause of the erectile failure becomes less important than
the fear of failure

Slide 21

Disorders of Excitement
Sociocultural causes
Each of the sociocultural factors tied to
hypoactive sexual desire has also been linked to
ED
Job and marital distress are particularly relevant

Slide 22

Disorders of Orgasm
Orgasm phase of the sexual response cycle
Sexual pleasure peaks and sexual tension is released as
the muscles in the pelvic region contract rhythmically
For men: semen is ejaculated
For women: the outer third of the vaginal walls contract

There are three disorders of this phase:

Premature ejaculation
Male orgasmic disorder
Female orgasmic disorder
Slide 23

Disorders of Orgasm
Premature ejaculation
Characterized by persistent reaching of orgasm and
ejaculation with little sexual stimulation
About 30% of men experience premature ejaculation at some time

Psychological, particularly behavioral, explanations of

this disorder have received more research support than
other theories
The dysfunction seems to be typical of young, sexually
inexperienced men
It may also be related to anxiety, hurried masturbation
experiences, or poor recognition of arousal

Slide 24

Disorders of Orgasm
Male orgasmic disorder
Characterized by a repeated inability to reach
orgasm or by a very delayed orgasm after normal
sexual excitement
Occurs in 8% of the male population

Biological causes include low testosterone,

neurological disease, and head or spinal injury
Medications, including certain antidepressants
(especially SSRIs) and drugs that slow down the CNS,
can also affect ejaculation

Slide 25

Disorders of Orgasm
Male orgasmic disorder
A leading psychological cause appears to be
performance anxiety and the spectator role, the
cognitive factors involved in ED

Slide 26

Disorders of Orgasm
Female orgasmic disorder
Characterized by persistent delay in or absence of orgasm
following normal sexual excitement
Almost 25% of women appear to have this problem
10% or more have never reached orgasm
An additional 10% reach orgasm only rarely
Women who are more sexually assertive and more comfortable
with masturbation tend to have orgasms more regularly
Female orgasmic disorder appears more common in single
women than in married or cohabiting women

Slide 27

Disorders of Orgasm
Female orgasmic disorder
Most clinicians agree that orgasm during intercourse is
not mandatory for normal sexual functioning
Early psychoanalytic theory used to consider lack of orgasm
during intercourse to be pathological

Typically linked to female sexual arousal disorder

The two disorders tend to be studied and treated together

Once again, biological, psychological, and sociocultural

factors may combine to produce these disorders

Slide 28

Disorders of Orgasm
Female orgasmic disorder
Biological causes
A variety of medical conditions can affect a womans arousal and
orgasm
These conditions include diabetes and multiple sclerosis
The same medications and illegal substances that affect erection
in men can affect arousal and orgasm in women
For example, as many as 40% of women who take Prozac
and other SSRIs may have problems with orgasm or arousal
Postmenopausal changes may also be responsible

Slide 29

Disorders of Orgasm
Female orgasmic disorder
Psychological causes
The psychological causes of hypoactive sexual desire
and sexual aversion may also lead to female arousal
and orgasmic disorders
Memories of childhood trauma and relationship
distress may also be related

Slide 30

Disorders of Orgasm
Female orgasmic disorder
Sociocultural causes
For decades, the leading sociocultural theory of female
sexual dysfunction was that it resulted from sexually
restrictive cultural messages
This theory has been challenged because:
Sexually restrictive histories are equally common in women
with and without disorders
Cultural messages about female sexuality have been changing
while the rate of female sexual dysfunction stays constant

Slide 31

Disorders of Orgasm
Female orgasmic disorder
Sociocultural causes
Researchers suggest that unusually stressful events,
traumas, or relationships may produce the fears,
memories, and attitudes that characterize these
dysfunctions
Research has also linked certain qualities in a womans
intimate relationships (such as emotional intimacy) to
orgasmic behavior

Slide 32

Disorders of Sexual Pain

Two sexual dysfunctions do not fit neatly into

a specific phase of the sexual response cycle

These are the sexual pain disorders:
Vaginismus
Dyspareunia

Slide 33

Disorders of Sexual Pain

Vaginismus
Characterized by involuntary contractions of the
muscles of the outer third of the vagina
Severe cases can prevent a woman from having
intercourse
Perhaps 20% of women occasionally have pain during
intercourse, but less than 1% of all women have
vaginismus

Slide 34

Disorders of Sexual Pain

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

Some women experience painful intercourse because of

infection or disease, leading to rational vaginismus
Most women with vaginismus also have other sexual
disorders
Slide 35

Disorders of Sexual Pain

Dyspareunia
Characterized by severe pain in the genitals during sexual
activity
Affects almost 15% of women and about 3% of men

Dyspareunia in women usually has a physical cause, most

commonly from injury sustained in childbirth
Although relationship problems or psychological trauma
from abuse may contribute to dyspareunia, psychosocial
factors alone are rarely responsible

Slide 36

Treatments for Sexual Dysfunctions

The last 35 years have brought major changes

in the treatment of sexual dysfunction

Early 20th century: psychodynamic therapy
Believed that sexual dysfunction was caused by a
failure to negotiate the stages of psychosexual
development
Therapy focused on gaining insight and making broad
personality changes; was generally unhelpful

Slide 37

Treatments for Sexual Dysfunctions

1950s and 1960s: behavioral therapy
Behavioral therapists attempted to reduce fear by
applying relaxation training and systematic
desensitization
Had moderate success, but failed to work in cases
where the key problems were cognitive or
psychoeducational

Slide 38

Treatments for Sexual Dysfunctions

1970: Human Sexual Inadequacy
This book, written by William Masters and
Virginia Johnson, revolutionized treatment of
sexual dysfunctions
This original sex therapy program has evolved
into a complex, multidimensional approach
Includes techniques from cognitive, behavioral,
couples, and family systems therapies
More recently, biological interventions have also been
incorporated

Slide 39

What Are the General

Features of Sex Therapy?
Modern sex therapy is short-term and

instructive
Therapy typically lasts 15 to 20 sessions
It is centered on specific sexual problems rather
than on broad personality issues

Slide 40

What Are the General

Features of Sex Therapy?
Modern sex therapy includes:
Assessing and conceptualizing the problem
Assigning mutual responsibility for the problem
Education about sexuality
Attitude change
Elimination of performance anxiety and the spectator role
Increasing sexual communication skills
Changing destructive lifestyles and marital interventions
Addressing physical and medical factors
Slide 41

What Techniques Are Applied

to Particular Dysfunctions?
In addition to the universal components of sex

therapy, specific techniques can help in each

of the sexual dysfunctions

Slide 42

What Techniques Are Applied

to Particular Dysfunctions?
Hypoactive sexual desire and sexual aversion
These disorders are among the most difficult to
treat because of the many issues that feed into
them
Therapists typically apply a combination of
techniques which may include:
Affectual awareness, self-instruction training,
behavioral techniques, insight-oriented exercises, and
biological interventions such as hormone treatments
Slide 43

What Techniques Are Applied

to Particular Dysfunctions?
Erectile disorder
Treatments for ED focus on reducing a mans
performance anxiety and/or increasing his stimulation
May include sensate-focus exercises such as the tease technique

Biological approaches, used when the ED has biological

causes, have gained great momentum with the recent
approval of sildenafil (Viagra)
Most other biological approaches have been around for decades
and include gels, suppositories, penile injections, a vacuum
erection device (VED), and penile implant surgery

Slide 44

What Techniques Are Applied

to Particular Dysfunctions?
Male orgasmic disorder
Like treatment for ED, therapies for this disorder
include techniques to reduce performance anxiety
and increase stimulation
When the cause of the disorder is physical,
treatment may include a drug to increase arousal
of the nervous system

Slide 45

What Techniques Are Applied

to Particular Dysfunctions?
Premature ejaculation
Premature ejaculation has been successfully treated for
years by behavioral procedures such as the stop-start or
pause technique
Some clinicians favor the use of fluoxetine (Prozac) and
other serotonin-enhancing antidepressant drugs
Because these drugs often reduce sexual arousal or orgasm, they
may be helpful in delaying premature ejaculation
While some studies have reported positive findings, long-term
outcome studies have yet to be conducted

Slide 46

What Techniques Are Applied

to Particular Dysfunctions?
Female arousal and orgasmic disorders
Specific treatment techniques for these disorders include
self-exploration, enhancement of body awareness, and
directed masturbation training
Again, a lack of orgasm during intercourse is not
necessarily a sexual dysfunction, provided the woman
enjoys intercourse and is orgasmic through other means
For this reason, some therapists believe that the wisest course of
action is simply to educate women whose only concern is lack of
orgasm through intercourse

Slide 47

What Techniques Are Applied

to Particular Dysfunctions?
Vaginismus
Specific treatment for vaginismus takes two
approaches:
Practice tightening and releasing the muscles of the
vagina to gain more voluntary control
Overcome fear of intercourse through gradual
behavioral exposure treatment

Over 75% of women treated for vaginismus using

these methods eventually report pain-free
intercourse
Slide 48

What Techniques Are Applied

to Particular Dysfunctions?
Dyspareunia
Determining the specific cause of dyspareunia is
the first stage of treatment
Given that most cases are caused by physical
problems, medical intervention may be necessary

Slide 49

What Are the Current Trends

in Sex Therapy?
Over the past 30 years, sex therapists have

moved beyond the approach first developed

by Masters and Johnson
Therapists now treat unmarried couples, those
with other psychological disorders, couples with
severe marital discord, the elderly, the medically
ill, the physically handicapped, clients with a
homosexual orientation, and clients with no longterm sex partner
Slide 50

What Are the Current Trends

in Sex Therapy?
Therapists are paying more attention to

excessive sexuality, which is sometimes

called sexual addiction
The use of medications to treat sexual

dysfunction is troubling to many therapists

They are concerned that therapists will choose
biological interventions rather than a more
integrated approach
Slide 51

Paraphilias
These disorders are characterized by unusual

fantasies and sexual urges or behaviors that

are recurrent and sexually arousing
Often involve:
Humiliation of self or partner
Children
Nonconsenting people
Nonhuman objects
Slide 52

Paraphilias
According to the DSM, paraphilias should be

diagnosed only when the urges, fantasies, or

behaviors last at least 6 months
For most paraphilias, the urges, fantasies, or
behaviors must also cause great distress or
impairment
For certain paraphilias, however, performance of the
behavior itself is indicative of a disorder
Example: sexual contact with children

Slide 53

Paraphilias
Some people with one kind of paraphilia display

others as well

Relatively few people receive a formal diagnosis, but

clinicians believe that the patterns may be quite common

Although theorists have proposed various

explanations for paraphilias, there is little formal

evidence to support the theories
None of the treatments applied to paraphilias have
received much research or proved clearly effective
Recent work has focused on biological interventions

Slide 54

Fetishism
The key features of fetishism are recurrent

intense sexual urges, sexually arousing

fantasies, or behaviors that involve the use of
a nonliving object
The disorder usually begins in adolescence
Almost anything can be a fetish
Womens underwear, shoes, and boots are especially
common
Slide 55

Fetishism
Researchers have been unable to pinpoint the

causes of fetishism
Psychodynamic theorists view fetishes as defense
mechanisms, but therapy using this model has
been unsuccessful

Slide 56

Fetishism
Behaviorists propose that fetishes are learned

through classical conditioning

Fetishes are sometimes treated with aversion therapy,
covert sensitization, or imaginal exposure
Another behavioral treatment is masturbatory satiation, in
which clients masturbate to boredom while imagining the
fetish object
An additional behavioral treatment is orgasmic
reorientation, a process which teaches individuals to
respond to more appropriate sources of sexual stimulation
Slide 57

Transvestic Fetishism
Also known as transvestism or cross-dressing
Characterized by fantasies, urges, or

behaviors involving dressing in the clothes of

the opposite sex in order to achieve sexual
arousal

Slide 58

Transvestic Fetishism
The typical person with transvestism is a

heterosexual male who began cross-dressing

in childhood or adolescence

Transvestism is often confused with gender

identity disorder (transsexualism), but the two

are separate patterns

The development of the disorder seems to

follow the behavioral principles of operant

conditioning
Slide 59

Exhibitionism
Characterized by arousal from the exposure of

genitals in a public setting

Also known as flashing
Sexual contact is neither initiated nor desired

Usually begins before age 18

Treatment generally includes aversion therapy and

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

Slide 60

Voyeurism
Characterized by repeated and intense sexual

desires to observe people in secret as they

undress or to spy on couples having
intercourse; may involve acting upon these
desires
The person may masturbate during the act of
observing or while remembering it later
The risk of discovery often adds to the excitement
Slide 61

Voyeurism
Many psychodynamic theorists propose that

voyeurs are seeking power

Others have explained it as an attempt to reduce
fears of castration

Behaviorists explain voyeurism as a learned

behavior that can be traced to a chance and

secret observation of a sexually arousing
scene
Slide 62

Frotteurism
A person who develops frotteurism has fantasies,

urges, or behaviors involving touching and rubbing

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

Usually begins in the teenage years or earlier

Acts generally decrease and disappear after age 25

Slide 63

Pedophilia
Characterized by fantasies, urges, or

behaviors involving sexual activity with a

prepubescent child, usually 13 years of age or
younger
Some people are satisfied with child pornography
Others are driven to watching, fondling, or
engaging in intercourse with children
Victims may be male, but evidence suggests that
two-thirds are female
Slide 64

Pedophilia
People with pedophilia develop the disorder in

adolescence
Some were sexually abused as children
Many were neglected, excessively punished, or
deprived of close relationships in childhood

Most are immature, display faulty thinking, and

have an additional psychological disorder
Some theorists have proposed a related biochemical or
brain structure abnormality

Slide 65

Pedophilia
Most people with pedophilia are imprisoned

or forced into treatment

Treatments include aversion therapy,
masturbatory satiation, and orgasmic reorientation
Cognitive-behavioral treatment involves relapseprevention training, modeled after programs used
for substance dependence

Slide 66

Sexual Masochism
Characterized by fantasies, urges, or

behaviors involving the act or thought of

being humiliated, beaten, bound, or otherwise
made to suffer
Most masochistic fantasies begin in childhood

and seem to develop through the behavioral

process of classical conditioning

Slide 67

Sexual Sadism
A person with sexual sadism finds fantasies,

urges, or behaviors involving the thought or

act of psychological or physical suffering of a
victim sexually exciting
Named for the infamous Marquis de Sade
People with sexual sadism imagine that they have
total control over a sexual victim

Slide 68

Sexual Sadism
Sadistic fantasies may first appear in

childhood
Pattern is long-term
Appears to be related to classical conditioning
and/or modeling

Psychodynamic and cognitive theorists view

people with sexual sadism as having

underlying feelings of sexual inadequacy
Slide 69

Sexual Sadism
Biological studies have found possible

abnormalities in the endocrine system

The primary treatment for this disorder is

aversion therapy

Slide 70

A Word of Caution
The definitions of paraphilias, like those of

sexual dysfunctions, are strongly influenced

by the norms of the particular society in
which they occur
Some clinicians argue that, except when

people are hurt by them, paraphilic behaviors

should not be considered disorders at all

Slide 71

Gender Identity Disorder

Gender identity disorder, or transsexualism, is

one of the most fascinating disorders related

to sexuality
People with this disorder persistently feel that
they have been assigned to the wrong biological
sex
They would like to remove their primary and
secondary sex characteristics and acquire the
characteristics of the opposite sex
Slide 72

Gender Identity Disorder

Men with GID outnumber women 2 to 1
People with GID often experience anxiety or

depression and may have thoughts of suicide

Slide 73

Gender Identity Disorder

People with gender identity disorder usually feel

uncomfortable wearing the clothes of their own sex

and may cross-dress
This is distinctly different from a transsexual fetish; there
is no sexual arousal related to this disorder

The disorder sometimes emerges in childhood and

disappears with adolescence

In some cases it develops into adult gender identity
disorder
Slide 74

Gender Identity Disorder

Several theories have been proposed to explain this

disorder, but research is limited and generally weak

Some clinicians suspect biological factors
Abnormalities in the hypothalamus (particularly the bed nucleus
of stria terminalis) are a potential link

Some adults with this disorder change their sexual

characteristics by way of hormones; others opt for

sexual reassignment (sex-change) surgery

Slide 75