Chapter 16
Sexual Disorders
Historical Perspective
• St-Augustine declared that sexual intercourse
was only allowed for procreation, only when the
man was on top, and only when the penis and
vagina were involved
• Many believed that masturbation caused a
variety of illnesses (see Tissot, 1758)
– Onania, or the Heinous Sin of Self-Pollution, And All
Its Frightful Consequences, in Both Sexes,
Considered was published in 19 editions and sold
38,000 copies before 1750
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Figure 10.3 The human sexual response cycle.
Sexual Disorders:
Diagnosis & Classification
Must cause marked distress or interpersonal difficulty
Specify:
Lifelong (primary) vs. acquired (secondary)
Global vs. Situational
Gradual vs. Sudden onset
Course: stable, improving, worsening
Differentiate if secondary to a medical or psychiatric
condition
Physical disease
Substance abuse
Other Axis I disorder
Chapter 16 Medication
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Sexual Dysfunction Disorders
Sexual desire disorders
Sexual arousal disorders
Orgasmic disorders
Sexual pain disorders
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Sexual Desire Disorders
• Hypoactive Sexual Desire Disorder—
persistently deficient or absent sexual
fantasies and desires
• Sexual Aversion Disorder—persistently
extreme aversion to, and avoidance of,
sexual contact with another person
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Causes of low desire in women
PSYCHOLOGICAL FACTORS
Losses
Trauma
Past sexual and non-sexual relationships
Cultural and religious attitudes
CONTEXTUAL FACTORS
Current interpersonal difficulties
Partner sexual dysfunction
Inadequate stimulation
Unsatisfactory sexual and emotional contexts
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Causes of low desire in women
MEDICAL FACTORS
Menopause (Low androgens)
Endocrine disorders (hypo-gonadism)
Medical procedures (hysterectomy, radiotherapy, chemo)
General poor health
Fatigue
Depression
Lactation (prolactin)
Hormone replacement therapy & oral contraceptives
SSRIs & other antidepressants
Antipsychotics
Narcotics or other substance abuse
Cardiac
medications (Ca & Beta blockers)
Chapter
16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Sexual Arousal Disorders
Persons with sexual arousal disorders experience
sexual desire, but are unable to maintain arousal
during intercourse
Female sexual arousal disorder involves inadequate
vaginal lubrication
Male erectile disorder involves failure to maintain an
erection during intercourse


Chapter 16
Can be induced by disease, drugs or depression
Most common sexual problem for which men consult with
specialists (50% of referrals)
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Ch 14.15
Sexual Arousal Disorders
Male Erectile Disorder (ED)
Etiology

Medical




Chapter 16
Diseases (diabetes, cardiovascular or prostate
problems)
Pelvic trauma
Medications (antidepressants, anti-hypertensives)
Treatments (prostate surgery, dialyses)
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Etiology of ED
Psychological
Depression
Anxiety
Obsessive-compulsive disorder
 Performance anxiety

Trauma (e.g., abuse)
Fear

Pregnancy, STDs
History of premature ejaculation
Sexual orientation conflict
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Etiology of ED
Relationship
Anger
Passive-aggressive
 Power struggle

Loss of sexual interest
Partner sexual dysfunction
Suspected infidelity
Commitment issues
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Orgasmic Disorders
Female orgasmic disorder refers to the absence of
orgasm after a period of normal sexual excitement
Female orgasmic disorder may reflect



Difficulty in learning to become orgasmic
Chronic use of alcohol
Fear of losing control
Male orgasmic disorder refers to difficulty in
ejaculation
Premature ejaculation is early ejaculation
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Ch 14.16
Male Orgasmic Disorder
Inability to reach orgasm after sufficient
stimulation
Often requires manual or oral stimulation
Experienced as “hard work”
Rare (< 1%)
Physiological etiology

High orgastic threshold


Chapter 16
Other side of the curve from PEs
SSRIs
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Male Orgasmic Disorder
Psychological etiology
Anxiety

Including performance anxiety
Depression
Abuse history
Relationship issues

Chapter 16
Anger
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Causes of anorgasmia in women
BIOLOGICAL
Selective serotonin reuptake inhibitors (SSRIs)
Especially those with primarily serotonergic and not
dopaminergic or noradrenergic effects
Antipsychotic medications (that decrease dopamine)
PSYCHOLOGICAL
Lack of information about sexual anatomy
Less education
Being younger
Higher religiosity  higher sex guilt
High anxiety
Inability to “let go”
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Sexual Pain Disorders
Dyspareunia refers to persistent or recurrent
pain during sexual intercourse
Associated with depression, anxiety and marital
difficulties
Vaginismus refers to an inability to achieve
intercourse due to involuntary spasms of
the outer third of the vagina
Associated with fear of pregnancy, relationship
problems and negative attitudes toward sex
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Ch 14.17
Causes of Vaginismus
BIOLOGICAL FACTORS
Pelvic floor muscle problems
PSYCHOLOGICAL FACTORS
Maintains balance in an unhealthy relationship
Protest against patriarchal norms that reduce
women to a lust object or a mother
Conditioned anxiety response**
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Historical Causes of Sexual
Dysfunction
Religious orthodoxy
involves negative views of
sexuality (procreation only,
not for pleasure)
Psychosexual trauma
Homosexual inclination:
sexual desire is impaired if
a homosexual engages in
sex with a heterosexual
Excessive alcohol intake
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
How do
sexual problems develop?
Predisposing
Factors
Early
Development
Chapter 16
Perpetuating
Factors
Precipitating
Factors
Current
Functioning
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
How do
sexual problems develop?
Predisposing


Childhood abuse or sexual assault
Early sexual experiences
Precipitating




Relationship distress
Major life changes such as parenthood, retirement
Menopause
Surgery or physical illness
Perpetuating




Performance anxiety
Poor communication
Lack of knowledge
Physical response (muscle tension)
Chapter 16
Laumann, Paik, Rosen, 1999, JAMA
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Causes of sexual aversion
A classically conditioned response
Unconditioned stimulus Conditioned stimulus
Assault
Chapter 16
+
Sex
Conditioned response

Fear, panic, and avoidance
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Predictors of sexual dysfunction
substance use
emotional problems
urinary tract problems
poor health
age (in men)
BIO
PSYCHO
stress
low overall
quality of life
sexual victimization
low SES
not in relationship
SOCIAL
Chapter 16
low sexual activity
not college educated
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Paraphilias: DSM-IV (1994)
“recurrent, intense sexually arousing fantasies,
sexual urges, or behaviours generally
involving 1) nonhuman objects, 2) the
suffering or humiliation of oneself or one’s
partner, or 3) children or other nonconsenting
persons that occur over a period of at least 6
months
“The urges or behaviour cause clinically
significant distress or impairment in social,
occupational, or other important areas of
Chapterfunctioning
16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
DSM-IV cont.
“…many individuals with these disorders
assert that the behaviour causes them
no distress and that their only problem
is social dysfunction as a result of the
reaction of others to their behaviour”
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Gender Differences
Except for S-M where the sex ratio is 20:1
males: females, the other paraphilias
are almost never diagnosed in women
Chapter 16
Peeping Tom
1960
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Paraphilias
Fetishism
Person uses inanimate objects as the
preferred or exclusive source of sexual
arousal.
Transvestitism
Fetish in which a heterosexual man dresses
in women’s clothing as his primary means of
becoming sexually aroused.
Sexual Sadism
Sexual gratification obtained through inflicting
pain and humiliation on one’s partner.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Paraphilias, continued
Sexual Masochism
Sexual gratification obtained through
experiencing pain and humiliation at the
hands of one’s partner.
Voyeurism
Obtainment of sexual arousal by compulsively
and secretly watching another person
undressing, bathing, engaging in sex, or being
naked.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Paraphilias, continued
Exhibitionism
Obtainment of sexual gratification by exposing
one’s genitals to involuntary observers.
Frotteurism
Obtainment of sexual gratification by rubbing
one’s genitals against or fondling the body
parts of a nonconsenting person.
Pedophilia
Adult obtainment of sexual gratification by
engaging in sexual activities with young
children.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Theories of fetish behaviour
Learning theory = result from classical conditioning
between fetish object and sexual arousal
Cognitive theory = cognitive distortion and perceiving an
unconventional stimulus as sexual
Monoamine hypothesis = problems in monoamine
(serotonin, norepinephrine, dopamine) metabolism
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Theories of fetish (cont.)
Imprinting hypothesis = adolescents are
vulnerable to imprinting of various stimuli;
thus, experiencing a stimulus at a critical
period can lead to imprinting
Addiction theory =
when a behaviour has salience
modifies mood
Tolerance
Withdrawal symptoms
Conflict
relapse
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Causes of Paraphilias
Theory
Description
Psychodynamic
theory
Fixation at early psychosexual stage or
regression to that stage.
Behavioral
Arousal is classical conditioned to a
previous neutral stimulus.
Social learning
Children whose parents engage in
aggressive, sexual behaviors with them
learned to engage in impulsive, aggressive,
sexualized acts toward others.
Cognitive
Distorted cognitions and assumptions about
sexuality lead to deviant sexual behavior.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: Cognitive Behavioural
Satiation  teach the individual to satiate
himself with the stimulus until arousal
decreases
Covert sensitization  associate negative
consequences to the precursors of his
atypical behaviour
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: Cognitive Behavioural
Fading  shift fantasies from atypical to
acceptable
Cognitive restructuring  challenge
cognitive distortions that justify to the
patient his atypical behaviour
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: Cognitive Behavioural
Victim empathy therapy  help patients
understand impact of their behaviour
Aversive stimulation  pair noxious
stimulus with the deviant fantasy in
order to interrupt the fantasy and
suppress the behaviour
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: Relapse Prevention
Help individual identify factors that trigger
a relapse
E.g., high risk situations, behavioural chains
that lead up to the problem behaviour,
strategies to avoid these factors
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: 12-Step
Sexaholics Anonymous
Sex Addicts Anonymous
Peer-lead
Modelled after AA
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: Medical
Antiandrogens
High rate of side effects, poor patient
motivation, and high drop-out rates
Implant GnRH analogues (leads to lowered LH
and testosterone)
Medroxyprogesterone acetate
Side effects: osteopenia, osteoporosis
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatments: Medical
Selective Serotonin Reuptake Inhibitors
(SSRIs)
50-90% efficacy
Also targets the low mood and anxiety
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Other helpful adjuncts to treatment
Social skills training
Assertiveness skills training
Sex education
Couples therapy
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Gender Identity Disorder
A person’s belief that they were born
with the wrong sex’s genitals and are
fundamentally persons of the
opposite sex.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
DSM-IV Criteria for Gender Identity
Disorder
A. Strong and persistent identification with the
other sex. In children, this is manifest by
four or more of the following:
1.
2.
3.
4.
5.
Chapter 16
Repeatedly stated desire to be, or insistence that he or
she is, the other sex;
In boys, preference for cross-dressing or simulating female
attire; in girls, insistence on wearing only stereotypical
masculine clothing;
Strong and persistent preferences for cross-sex roles in
play and in fantasies;
Intense desire to participate in the stereotypical games
and pastimes of the other sex;
Strong preference for playmates of the other sex.
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
DSM-IV Criteria for Gender Identity
Disorder, continued
B. Persistent discomfort with his or her sex and
a sense of inappropriateness in the gender
role of that sex.
C. Disturbance is not concurrent with a physical
intersex condition and causes significant
distress or problems.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.
Treatment of Gender Identity
Disorder
Therapists do not try to “cure” people with
gender identity disorder by convincing them
to accept the body with which they were born.
Gender reassignment requires several
surgeries and hormone treatments and is
primarily cosmetic. It remains a controversial
practice.
Chapter 16
Copyright © 2004 by The McGraw-Hill Companies, Inc. All rights reserved.