Clinical psychology
Chapter 12
Sexual disorders

Sexual dysfunctions are defined by persistent disruptions in the ability to experience sexual arousal, desire, orgasm, or by pain associated with intercourse.
Paraphilias are defined by persistent and troubling attractions to unusual sexual activities or objects.

Sexual norms and behavior

Definitions of what is normal or desirable in human sexual behavior vary with time and place.
Culture influences attitudes and beliefs about sexuality.

Gender and sexuality

Women tend to be more ashamed of any flaws in their appearance than do men, and this shame can interfere with sexual satisfaction.
For women, sexuality appears to be more closely tied to relationship, status, and social norms than for men.
Among women with sexual symptoms, more than half believe their symptoms are caused by relationship problems. Men are more likely to think about their sexuality in terms of power than are women.

There are many parallels in men’s and women’s sexuality.

• The primary motivation for having sex was sexual attraction and physical gratification.

The sexual response cycle

Four phases in the human sexual response cycle

1. Desire phase
2. Excitement phase
3. Orgasm phase
4. Resolution phase

Sexual dysfunctions

Sexuality usually occurs in the context of an intimate personal relationship.
Our sexuality shapes at least part of our self-concept.
When sexual problems emerge, they can wreak havoc on our self-esteem and relationships.

Clinical descriptions of sexual dysfunctions

The DSM-5 divides sexual dysfunctions into three categories:

• Involving sexual desire, arousal, and interest
• Orgasmic disorders
• Sexual pain disorders

Separate diagnoses are provided for men and women.

The diagnostic criteria for all sexual dysfunction specify that dysfunction should be persistent and recurrent and should cause clinically significant distress or problems with functioning.
A diagnoses of sexual dysfunction is not made it the problem is believed to be due entirely to a medical illness or another psychological disorder.

Many people with problems in one phase of the sexual cycle will often report problems in another phase. Some of this may just be a vicious circle.
Sexual problems in one person may lead to sexual problems in the partner.

Disorders involving sexual interest, desire, and arousal

DSM-5 criteria for Male hypoactive sexual desire disorder

• Sexual fantasies and desires, as judged by the clinician, are deficient or absent for at least 6 months.

DSM-5 criteria for Erectile disorder

• On at least 75 percent of sexual occasions for 6 months:
  • Inability to attain an erection, or
  • Inability to maintain an erection for completion of sexual activity, or
  • Marked decrease in erectile rigidity interferes with penetration or pleasure

DSM-5 criteria for Female sexual interest/arousal disorder

• Diminished, absent, or reduced frequency of at least three of the following for 6 months or more:
  • Interest in sexual activity
  • Erotic thoughts or fantasies
  • Initiation of sexual activity and responsiveness to partner’s attempts to initiate
  • Sexual excitement/pleasure during 75 percent of sexual encounters
  • Sexual interest/arousal elicited by any internal or external erotic cues
  • Genital or nongenital sensations during 75 percent of sexual encounters.

Three disorders relevant to sexual interest, desire, and arousal

• Female sexual interest/arousal disorder
  Persistent deficits in sexual interest, biological arousal, or subjective arousal
• Male hypoactive sexual desire disorder
  Deficient or absent sexual fantasies and urges
• Erectile disorder
  Failure to attain or maintain an erection through completion of the sexual activity.

It is important to rule out biological explanations for these symptoms for both men and women.

Among people seeking treatment for sexual dysfunctions, more than half complain of low desire.
Women are more likely than men to report at least occasional concerns about their level of sexual desire.
Postmenopausal women are more likely to report low sexual desire. Older women are less likely to be distressed over this low sexual desire.
Occasional symptoms of erectile disorder are the most common sexual concern among men.
Male erectile disorder increases greatly with age.

Cultural norms seem to influence perceptions of how much sex a person ‘should’ want.

Orgasmic disorders

DSM-5 includes separate diagnoses for problems achieving orgasm in men and women.

• Female orgasmic disorder
  The persistent absence or reduced intensity of orgasm after sexual excitement.
  Women have different thresholds for orgasm.
  Not diagnosed unless the absence of orgasms is persistent and troubling.

Womens problems reaching orgasm are distinct from problems with sexual arousal.

Two orgasmic disorders of men:

• Premature ejaculation
  Ejaculation that occurs to quickly
• Delayed ejaculation disorder
  Persistent difficulty ejaculating

DSM-5 criteria for female orgasmic disorder

• On at least 75 percent of sexual occasions for 6 months:
  • Marked delay, infrequency, or absence of orgasm, or
  • Markedly reduced intensity of orgasmic sensation.

DSM-5 criteria for Premature ejaculation

• Tendency to ejaculate during partnered sexual activity within 1 minute of sexual activity on at least 75 percent of sexual occasions for 6 months.

DSM-5 criteria for Delayed ejaculation

• Marked delay, infrequency, or absence of orgasm on at least 75 percent of sexual occasions for 6 months.

Sexual pain disorders

Genito-pelvic pain/penetration disorder is defined by persistent or recurrent pain during intercourse.
For diagnoses, pain may not be caused by a medical problem.
It is extremely rare for men to seek treatment for these concerns.

Most women with this sexual disorder experience sexual arousal and can have orgasms from manual or oral stimulation that does not involve penetration.
Prevalence of 10 to 30 percent.

DSM-5 criteria for Genito-pelvic pain/penetration disorder

• Persistent or recurrent difficulties for at least 6 months with at least one of the following:
  • Inability to have vaginal/penetration during intercourse
  • Marked vulvovagnial 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.

Etiology of sexual dysfunctions

The immediate causes can be distilled down to two:

• Fears about performance
  Concerns about how one is performing during sex
• The adoption of a spectator role
  Being an observer rather than a participant in a sexual experience.

Sexual functioning is complex and multifaced.

Biological factors

Can include diseases such as atherosclerosis, diabetes, multiple sclerosis, and spinal cord injury.
Low levels of testosterone or estrogen, heavy alcohol use before sex, chronic alcohol dependence, and heavy cigarette smoking.
Certain medications.

Psychological factors

Some sexual dysfunctions can be traced to rape, childhood sexual abuse, or other degrading encounters.
Sexual abuse during childhood is associated with diminished arousal and desire, and, among men, with double the rate of premature ejaculation.

Beyond the role of traumatic experiences, it is important to consider the benefits of positive experiences, many people with sexual problems lack knowledge and skill because they have not had opportunities to learn about their sexuality.

Broader relationship problems often interfere with sexual arousal and pleasure.

• For women, concerns about a partner’s affection appear particularly correlated with sexual satisfaction.
• For people who tend to be anxious about their relationships, sexual problems may exacerbate underlying worries about relationship security.
• People who are angry with their partner are less likely to want sex.
• Even in couples who are satisfied in other realms of their relationship, poor communication can contribute to sexual dysfunction.

Depression and anxiety increase the risk of sexual dysfunctions.
Anxiety and depression are particularly comorbid with sexual pain and with disorders involving low sexual desire and arousal.

Low general physiological arousal can interfere with specific sexual arousal.
Too much stress and exhaustion clearly impede sexual functioning.

Negative cognitions interfere with sexual functioning.
Cognitions about sexual performance are particularly important. People who blame themselves for decreased sexual performance will be more likely to develop recurrent problems.

Treatment of sexual dysfunctions

The multifaced nature of sexual dysfunctions often requires the use of a combination of techniques.

Anxiety reduction

Gradual and systematic exposure to anxiety-provoking aspects of the sexual situation.
Systematic desensitization and in vivo desensitization have been employed with some success, especially when combined with skill training.

Simple psychoeducation programs about sexuality also do a great deal to reduce anxiety.
Psychoeducation can be as effective as systematic desensitization for male erectile disorder and for women with orgasmic disorder or low levels of sexual arousal.

For the treatment of premature ejaculation, anxiety-reduction techniques sometimes have a different focus.
Other sexual activities, so a couples anxieties about sex diminish.

Directed masturbation

Enhance women’s comfort with and enjoyment of their sexuality. Gradually from seeing yourself naked, to masturbation, to partner looking, to sex.
Helpful in treatment for orgasmic disorder.
Also helpful in treatment of low sexual desire.

Procedures to change attitudes and thoughts

In one cognitive approach, clients are encouraged to focus on the pleasant sensations that accompany even incipient sexual arousal.
The focus on physical sensations may counter the destructive tendency to think about one’s performance or attractiveness during sex.

Other cognitive interventions are designed to challenge the self-demanding, perfectionistic thoughts that often cause problems for people with sexual dysfunctions.

Skills and communication training

To improve sexual skill and communication, therapists assign written materials and show clients explicit videos demonstrating sexual techniques.
Encouraging partners to communicate their likes and dislikes to each other has been shown helpful for a range of sexual dysfunctions.
Skills and communication training also exposed partners to potentially anxiety-provoking material, which allows for a desensitizing effect.

Couples therapy

Troubled couples usually need training in nonsexual communication skills.

The paraphilic disorders

The paraphilic disorder are defined by recurrent sexual attraction to unusual objects or sexual activities lasting at least 6 months.

Accurate prevalence statistics are not available for the paraphilic disorders.
Most people wit ha paraphilic disorder meet criteria for other paraphilic disorders and for other DSM diagnoses such as mood and anxiety disorders.

Fetishistic disorder

DSM-5 criteria for fetishistic disorder

• For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviors involving the use of nonliving objects or nongenital body parts.
• Causes significant distress or impairment in functioning
• The sexually arousing objects are not limited to articles of clothing used in cross-dressing or to devices designed to provide tactile genital stimulation, such as a vibrator.

Fetishistic disorder is defined by a reliance on an inanimate object or a nongentical part of the body for sexual arousal.
A fetish refers to the object of these sexual urges. The person with fetishistic disorder, almost always a man, has recurrent and intense sexual urges toward these fetishes, and the presence of the fetish is strongly preferred or even necessary for sexual arousal.

Clothing, leather, and articles related to feet are common fetishes.
Some do the festism them selves, others need a partner to do the fetish as a stimulant for intercourse. For many, a fetish may never reach a diagnosable level.

The person with fetishistic disorder feels a compulsive attraction to the object. The attraction is experienced as involuntary and irresistible.

The disorder usually begins in adolescence, although the fetish may have acquired special significance even earlier, during childhood.
People with fetishistic disorder often have other paraphilias.

Pedophilic disorder and incest

DSM-5 criteria for Pedophilic disorder

• For at least 6 months, recurrent and intense, sexually arousing fantasies, urges, or behaviors involving sexual contact with a prepuberscent child
• Arousal is as strong or stronger for children than for adults
• Person as acted on these urges or the urges and fantasies cause clinically significant distress or interpersonal problems
• Person is at least 18 years old and 5 years older than the child

Pedophilic disorder is diagnosed when adults derive sexual gratification through sexual contact with prepuberal or pubercent children, or when they experience recurrent, intense, and distressing desires for sexual contact with prepuberal or pubescent children.
The offender must be at least 18 years old and at least 5 years older than the child.

People with pedophilic disorder generally molest children that they know.
Most with pedophilic disorder do not engage in violence other than the sexual act.

Incest is listed as a sub-type of pedophilic disorder.
Incest: sexual relations between close relatives for whom marriage is forbidden.
Families in which incest occurs are unusually patriarchal, especially with respect to the subservient position of women to men. Parents in these families also tend to be more neglectful and emotionally distant from their children.

Typically, men who commit incest abuse their pubescent daughters, whereas men with nonincestual pedophilic disorder are usually interested in prepuberal children.

Academic problems are common, as are other criminal behaviors.
Men with pedophilic disorder demonstrate elevated impulsivity and psychopathy compared to the general population.
These men often meet criteria for comorbid conduct disorder and substance use disorder. Molestations are more likely to occur when the person with pedophilic disorder is intoxicated.
Depression and anxiety are also common.

Voyeuristic disorder

DSM-5 criteria for Voyeuristic disorder

• For at least 6 months, recurrent and intense sexually arousing fantasies, urges, or behaviors involving the observation of unsuspecting others who are naked, disrobing, or engaged in sexual activity
• Person has acted on these urges with a nonconsenting person, or the urges and fantasies caused marked distress or interpersonal problems.

Voyeuristic disorder involves an intense and recurrent desire to obtain sexual gratification by watching unsuspecting others in a state of undress or having sexual relations.
The looking helps the person become sexually aroused and is sometimes essential for arousal.
The element of risk seems important, for the voyeur is excited by the anticipation of how the women would react if she knew he was watching.

Typically begins in adolescence.
Often also have other paraphilias, but they do not tend to have elevated rates of other mental disorders.

Exhibitionistic disorder

DSM-5 criteria for Exhibitionistic disorder

• For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviors involving showing one’s genitals to an unsuspecting person.
• Person has acted on these urges to a nonconsenting person, or the urges and fantasies cause clinically significant distress or interpersonal problems.

Exhibitionistic disorder is a recurrent, intense desire to obtain sexual gratification by exposing one’s genitals to an unwilling stranger, sometimes a child.
Typically begins in adolescence.
There is seldom an attempt to have actual contact with the stranger.
In most cases, there is a desire to shock or embarrass the observer.

The urge is overwhelming and virtually uncontrollable and is apparently triggered by anxiety and restlessness as well as by sexual arousal.

Other paraphilias are very common in exhibitionists, notably voyeuristic and frotteuristic disorders.

Frotteuristic disorder

DSM-5 criteria for Frotteuristic disorder

• For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviors involving touching or rubbing against a nonconsenting person.
• Person has acted on these urges with a nonconsenting person, or the urges and fantasies cause clinically significant distress or problems.

Frotteuristic disorder involves the sexually oriented touching of an unsuspecting person.
Typically occurs along with other paraphilias.

Sexual sadism and masochism disorders

DSM-5 criteria for Sexual sadism disorder

• For at least 6 months, recurrent and intense and sexually arousing fantasies, urges, or behaviors involving the physical or psychological suffering of another person
• Causes clinically significant distress or impairment in functioning or the person has acted on these urges with a nonconsenting person.

DSM-5 criteria for Sexual masochism disorder

• For at least 6 months, recurrent, intense, and sexually arousing fantasies, urges, or behaviors involving the act of being humiliated, beaten, bound, or made to suffer
• Causes marked distress or impairment in functioning.

Sexual sadism disorder is defined by an intense and recurrent desire to obtain or increase sexual gratification by inflicting pain or psychological suffering on another.

Sexual masochism disorder is defined by an intense and recurrent desire to obtain or increase sexual gratification through being subjected to pain or humiliation.

Sexual sadism and masochism disorders seem to begin by early adulthood.
Found in straight and gay relationships.
Similar gender ratio.
Alcohol abuse is common among sadists.

Etiology of paraphilic disorders

Neurobiological factors

The overwhelming majority of people with paraphilic disorders are men.
Androgens (hormones like testosterone) may play a role.
Androgens regulate sexual desire, and sexual desire appears to be atypically high among people with paraphilic disorders.
But, men with paraphilic disorders do not appear to have high levels of testosterone or other androgens.

Psychological factors

Dominant models emphasize conditioning experiences, relationship histories, abuse, and cognition.

Some behavioral theorists view the cause of paraphilic disorders, as classical conditioning that by change has linked sexual arousal with unusual or inappropriate stimuli.

From an operant conditioning perspective, some paraphilic disorders are considered an outcome of inadequate social skills.
Paraphilias may be activities that substitute for more conventional relationships and sexual activity.
But, it is more complex.

People with paraphilic disorders were often exposed to physical abuse, sexual abuses, an poor parent-child relationships.

Cognitive distortions and attitudes play a role in paraphilic disorders.

Alcohol and negative affect are often the immediate triggers of incidents of pedophilic disorder, voyeuristic disorder, and exhibitionistic disorder.

Treatments for the paraphilic disorders

Strategies to enhance motivation

To enhance motivation for treatment, a therapist can do the following:

• Empathize within the offender’s reluctance to admit that he is an offender and to seek treatment, thereby reducing defensiveness and hostility
• Point out that treatment might help him control his behavior better
• Emphasize the negative consequences of refusing treatment and of offending again.
• Explain that the psychophysiological assessment of the patient’s sexual arousal will make it harder to deny sexual proclivities to the authorities

Cognitive behavioral treatment

Aversion therapy.

Cognitive procedures are often used to counter the distorted thinking of people with paraphilic disorders.
Supplement traditional approaches with techniques such as social skills training and sexual impulse control training.
Training in empathy toward others.
Relapse prevention, help a person identify situations and emotions that might trigger symptomatic behaviors.

Biological treatment

Hormonal agents that reduce androgens.
And SSRI antidepressants are commonly used.
Typically to supplement psychological treatment.