Psyc212 Sexual And Gender Idnetity Disorders 8

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Sexual dysfunctions

Paraphilic Disorders

Gender dysphoria

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• Sexual dysfunctions: difficulty functioning adequately while having sex.

• Paraphilic Disorders: abnormal attractions or desires.

• Gender dysphoria: psychological dissatisfaction with one's natal sex.

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Sexual dysfunction

Types of disorders (Males and Females)

• Desire

• Arousal

• Orgasm

• Pain

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• Desire:

Male: hypoactive sexual disorder (little or no desire to have sex)

Female: Female sexual interest/arousal disorder• Arousal:

Men: erectile disorder (difficulty maintaining erections)

Female sexual interest/arousal disorder• Orgasm:

Male: Delayed /pre-mature ejaculation

Female: female orgasmic disorder • Pain:

Female: genito-pelvic pain/penetration disorder

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Male hypoactive sexual desire disorder

Diagnosis Criteria

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A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity. The judgement of deficiency is made by the clinician taking into account factors that affect sexual functioning, such as age and general and socio-cultural contexts of the individuals life.

B. Criteria A symptoms have persisted for a minimum of 6 months.

C. Criteria A symptoms cause clinically singnificant distress.

D. The sexual dysfunction is not better explained by a non sexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

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Erectile Disorder

Diagnostic Criteria

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A. At least one of the three symptoms must be experienced on almost all or all occasions of sexual activity.

1. Marked difficulty in mainting an erection during sexual activities

2. Marked difficulty in maintaining an erection until the completion of sexual activity.

3. Marked decreased in erectile rigidity.

B. Croteria A symptoms have persisted for a min of 6 months

C. Criteria A symotoms cause clinically significant distress.

D. The sexual dysfucntion is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or ther significant stressors and is not attributable to the effects of substance/medication or another medical condition.

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Erectile Disorder

Diagnostic Criteria

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A. At least one of the three symptoms must be experienced on almost all or all occasions of sexual activity.

1. Marked difficulty in mainting an erection during sexual activities

2. Marked difficulty in maintaining an erection until the completion of sexual activity.

3. Marked decreased in erectile rigidity.

B. Croteria A symptoms have persisted for a min of 6 months

C. Criteria A symotoms cause clinically significant distress.

D. The sexual dysfucntion is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or ther significant stressors and is not attributable to the effects of substance/medication or another medical condition.

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Female sexual interest and arousal disorder

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A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at least three of the following:1. Absent/reduced interest in sexual activity.2. Absent/reduced sexual/erotic thoughts or fantasies. 3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to initiate. 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (75 – 100%) of sexual encounters. 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual erotic cues (e.g., written, verbal, visual).6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (75 – 100%) of sexual encounters.

B. Criteria A symptoms have persisted for a minimum of 6 months.

C. Criteria A symptoms cause clinically significant distress.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

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Delayed Ejaculation

Diagnostic Criteria

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A. Either of the following symptoms must be experienced on almost all or all occasions (75 – 100%) of partnered sexual activity (in identified situational contexts or, if generalised, in all contexts), and without the individual desiring delay:1. Marked delay in ejaculation. 2. Marked infrequency or absence of ejaculation.

B. Criteria A symptoms have persisted for a minimum of 6 months.

C. Criteria A symptoms cause clinically significant distress.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. -8% of males reporting having had delayed/absent orgasms.-Clinical presentation and diagnosis is rare.

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Pre-mature (Early Ejaculation)

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A. A persistent or recurrent pattern of ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes. Note: Although this diagnosis may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities.

B. Criteria A symptoms have persisted for a minimum of 6 months.

C. Criteria A symptoms cause clinically significant distress.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Occurs in 21% of men, declines with age (more common in younger, inexperienced males).

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Female orgasmic disorder

Diagnostic Criteria

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A. Presence of either of the following symptoms and experienced on almost all or all (75 – 100%) occasions of sexual activity (in identified situational contexts or, if generalised, in all contexts):1. Marked delay in, marked infrequency of, or absence of orgasm. 2. Markedly reduced intensity of orgasmic sensations.

B. Criteria A symptoms have persisted for a minimum of approximately 6 months.

C. Criteria A symptoms cause clinically significant distress.

D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. Most common complaint of females seeking assistance for sexual dysfunction: 25% of women report difficulty reaching orgasm (prevalence of the disorder unknown).

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Sexual Pain Disorders -Genito-Pelvic Pain/Penetration Disorder

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A. Persistent or recurrent difficulties with one (or more) of the following:Vaginal penetration during intercourse.1. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts. 2. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration. 3. Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration. B. Criteria A symptoms have persisted for a minimum of approximately 6 months.C. Criteria A symptoms cause clinically significant distress. D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition. Occurs in 7% of females.

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Assessing Sexual Behaviour

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Interviews:• Clinicians must demonstrate comfort/put the patient at ease• Use the language of the patient• Cover nonsexual relationship issues and physical and psychological health• Inclusion of partners in interview

Medical Evaluation:• Medical conditions that affect sexual functioning• Medications• Recent surgeries• Hormone levels

Psychophysiological Assessment:• Measuring the sexual arousal response

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Causes of Sexual Dysfunction

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Biological factors:• Medical conditions (directly and indirectly)• Drugs (licit and illicit)

Psychological factors:• ?Anxiety• Distraction

Social factors: • Negative associations due to childhood experiences (erotophobia) • Other relationship issues• Lack of communicationSexual dysfunction is likely to be the result of a subtle combination of all the above factors.

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Treatment of Sexual Dysfunction

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Psychological treatments:• Education (HIGHLY effective)• Couples therapy based on the work of Masters and Johnson:

▪︎Enhance communication between partners

▪︎Eliminate performance anxiety

▪︎Sensate focus

▪︎Nondemand pleasuring

▪︎Specific techniques for specific issues are best incorporated into this therapy

Medical treatments:• Almost all focus on male erectile dysfunction• Oral medication (combined with CBT)• Injections• Surgery (penile prosthesis or implants)• Vacuum Device Therapy

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Paraphilic Disorders

Clinical Description

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Paraphilia: any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. • Often people have multiple paraphilias (one dominant) • Comorbid mood, anxiety and substance use disorders • Many dozen types of paraphilias (not just those discussed here)

Paraphilic disorder: a paraphilia that, 1. Causes distress or impairment to the individual, OR2. Whose satisfaction has entailed personal harm, or risk of harm, to others.

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Types of Paraphilic Disorders

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Fetishistic disorder: recurrent and intense sexual arousal from with the use of nonliving objects or highly specific focus on nongenital body part(s), as manifested by fantasies, urges or behaviours.

Voyeuristic disorder: recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity, as manifested by fantasies, urges or behaviours.

Exhibitionist disorder: recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges or behaviours.

Frotteuristic disorder: recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person, as manifested by fantasies, urges or behaviours.

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More types of paraphilic disorders

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Sexual masochism disorder: recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer, as manifested by fantasies, urges or behaviours.

Sexual sadism disorder: recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges or behaviours.

Pedophilic disorder: recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child or children (generally age 13 or younger).

Transvestic disorder: recurrent and intense sexual arousal from cross-dressing as manifested by fantasies, urges or behaviours.

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Causes of paraphilic disorders

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• An inability to develop adequate social relations with the appropriate people for sexual relationships seems to be associated with developing inappropriate sexual outlets

• Early experiences▪︎Inappropriate arousal/fantasy – reinforced through sexual pleasure brought about through masturbation (operant conditioning paradigm)

▪︎Disordered relationships during childhood and adolescence with resulting deficits in healthy sexual development

• Low levels of arousal to appropriate stimuli • Strong sex drive• Weak behavioural inhibition system (restricted ability to suppress urges/drive)

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Psychological Treatments

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• Most are directed at changing the associations and context from arousing and pleasurable to neutral. • Covert sensitization: patients associate sexually arousing images in their imagination with some reasons why the behaviour is harmful or dangerous. • Family, marital therapy• Orgasmic reconditioning: to help strengthen appropriate patterns of arousal. • Relapse prevention techniques (i.e., recognising early signs of temptation and instituting a variety of self-control procedures before these urges become too strong). • Evidence of effectiveness of these treatments is mixed – potentially more effective for less severe cases.

▪︎Men who rape have the lowest response rate.

▪︎People with multiple paraphilias are also more resistant to treatment.

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Drug treatments - paraphilia

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• Cyproterone acetate (“chemical castration”; eliminates sexual desire and fantasy)• Medroxyprogesterone (Depo-Provera)

• Useful for dangerous sex offenders who do not respond to other treatments • High relapse rate when drug is discontinued

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Gender Dysphoria

Clinical overview

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• A marked incongruence between ones assigned gender and their experienced gender

• Must distinguish from:▪︎ Transvestic fetishism (this is to do with sexual arousal)▪︎Disorders of sexual development (congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical)▪︎ Homosexual arousal patterns

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Gener Dysphoria Key Terms

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Sex: biological indicators of male and female understood in the context of reproductive capacity (sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia).

Gender: the public (and usually legally recognised) lived role as boy or girl, man or woman.

Gender dysphoria: refer to the distress that may accompany incongruence between one’s experienced or expressed gender and one’s assigned gender. This is more descriptive than the previous DSM-IV term gender identity disorder and, importantly, focuses on dysphoria as the clinical problem, not identity per sex.

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Gender Dysphoria - In Children

Diagnostic Criteria

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A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 mnths duration, as manifested by at least six of the following (one of which must be Criterion A1):1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender). 2. In boys, a strong preference for cross-dressing or simulating female attire; or in girls, a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one’s sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

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Gender Dysphoria in Adolescents and Adults

Diagnostic Criteria

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A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, as manifested by at least two of the following:1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s expressed/experienced gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender difference from one’s assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

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Gender Dysphoria Controversies

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• One argument is that gender characteristics are socially constructed and therefore naturally unrelated to biological sex

• Cisgenderism: the socio-cultural ideology that promotes and reinforces dominant binary gender systems, provides justification for stigma towards transgender people, and delegitimises people’s own understanding of their genders and bodies

• Many people who would be considered to have gender dysphoria do not regard their own feelings and behaviours as a “disorder”; they may question what a “normal” gender identity or role is supposed to be

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Causes, Gender Dysphoria

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• Something of a mystery

Biological:

• Likely genetic contributions – link unclear

• In virto exposure to hormones

• Slightly higher levels of testosterone or estrogen at certain critical periods of development might masculinize a female fetus or feminize a male fetus – link unclear.

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Gender Dysphoria

Treatment

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Sex reassignment surgeryMust first:▪︎ Live in the opposite sex role for 1 – 2 years▪︎ Be psychologically, financially, and socially stable ▪︎ Have hormone therapy (development and expression of secondary sex characteristics) •75% adjust well/are satisfied with surgery; 7% later regret the surgery (2% attempt suicide)•People who undergo female-to-male conversions generally adjust better

Treatment of gender non-conformity in children▪︎Work with child and caregivers to lessen gender dysphoria and decrease cross gender behaviours▪︎“Watchful waiting”▪︎Actively affirming and encouraging cross-gender identification