Sexual Disorders
Human Sexual
Response Cycle
Appetitive
 Excitement
 Orgasm
 Resolution

Appetitive

Fantasies about sexual activity and the
desire (i.e., libido) to have it
Excitement
Subjective sense of sexual pleasure with
accompanying physiologic changes (maleerection; females-vasoconstriction, vaginal
lubrication, and swelling of external
genitalia). Mediated by the
parasympathetic nervous system
 Excitement and Plateau (M&J, 1970)
 Vascular stage (Kaplan, 1974)

Orgasm
The peaking of the sexual pleasure and the
release of sexual tension. Mediated by the
sympathetic nervous system (muscular
stage-Kaplan).
 Males sense inevitable ejaculation, which is
followed by a single, intense muscular
contraction that emits semen. In a more
variable response, females contract the
outer third of their vagina.

Resolution

A generalized and muscular relaxation,
during which males* are physiologically
refractory to further erection or orgasm,
whereas females can respond immediately
to additional stimuli
Sexual Dysfunctions
2nd most common group of mental d/o’s
 Must be

– persistent and recurrent
– not occurring exclusively during the course of
another Axis I d/o (Ex. Dep. or Sub. Abuse)
– causes marked distress and interpersonal diff..

Specifiers-livelong/acquired;
generalized/situational; conjoint/solitary;
psychological/combined factors
Sex. Dysf. continued

MOST COMMON FAILURE IS NEGLECTING
TO R/O GMC
– 43% Women & 31% Men (Laumann, 99)


Note-frequency, setting, duration, degree of sexual
impairment, level of subjective distress & other
areas affected.
Associated with traits-Ex. Histrionic women may
have inhibited desire & orgasm. OCD men may
have inhibited sexual desire & excitement.
Anxiety-PE & impotence
Phase I Sexual Dysf.
Hypoactive sexual desire disorderdeficiency (or absence) of sexual fantasies
and desires for sexual activity. Women>
men & accompanied by other sexual dys.
 Sexual aversion disorder-an extreme
aversion to and avoidance of all (or almost
all) genital sexual contact with a partner

Arousal/Excitement D/O’s



Female sexual arousal & Male erectile d/odisorders in which prior to the sexual act being
concluded, there is a partial or complete failure in
men to maintain erection (impotence) or in women
to attain the lubrication-swelling response. Due to
surgery, physical illness and psychological issues.
Viatra?
Eros-CTD
ED across the lifespan
<1% of men < 19 report ED
 10-33% of men > 60
 Probability of complete impotence triples
from 5.1% to 15% in midlife (>40)
 Estimated over 20 million men afflicted

ED & Acute causes*
Antihypertensive medication (14%)
 Cardiac medication (28%)
 Glaucoma eyedrops
 Antianxiety, antidepressants, antipsychotics
 Prostrate Cancer and it’s treatments
 Several other meds. (Antihistamines,
AEDs)
 Psychological factors

ED & Chronic Illness*
Heart Disease-39% (Alhof & Sethel, 1995)
 Diabetes-38% (Carey et al., 1994)
 Hypertension-15% (Alhof & Sethel, 1995)

ED & Cultural factors
In India, semen is know as virya, which is
derived from the Sanskrit work meaning
bravery, power or strength. Loss of erection
is considered to cause depletion of physical
and mental energy, a belief deeply rooted in
Indian culture
 Higher rates of ED in more “restricted”
countries

Treatments

Urology exam to rule out GMC
– May lead to change in diet or medications

If psychological: Therapy
– Individual vs. Couples
– Traditional vs. Sex therapy

Medications, devices or implants
Orgasm Disorders
Female and male orgasmic disordersdisorders in which there is a delay in or
absence of orgasm following a normal
sexual excitement phase.
 Premature ejaculation-Male disorder in
which ejaculation occurs with minimal
sexual stimulation before, on, or shortly
after penetration and before the person
wishes it. Consider age, frequency, novelty
of sexual partner and duration.

Sexual Pain Disorders
Dyspareunia-recurrent or persistent genital
pain (usually in women but sometimes in
men) that occurs during or after intercourse
 Vaginismus-recurrent or persistent
involuntary muscular spasm of the outer
third of the vagina that interferes with
sexual intercourse by making penetration
difficult, painful or impossible.

Paraphillias

Involuntary and repeated need for unusual
or bizarre imagery, acts, or objects to induce
sexual excitement. Involving
– inanimate objects; suffering or humiliation; or
sexual activity with non-consenting partner

Rarely diagnosed. Key issue is during harm
or this being the sole way of obtaining
sexual gratification.
Transvestitism
Cross dressing to release anxiety or bring
sexual arousal
 Male gender identification
 No desire to get rid of male genitalia

Gender Identity Disorder

Strong and persistent cross-gender
identification (not merely a desire for any
perceived cultural advantages or being the
other sex)
GID cont.

In children:
– repeated stated desire to be other sex
– boys: cross-dressing or stimulation by female
attire; girls: stereotypical masculine clothing
– strong and persistent preference for cross-sex
roles during make believe play/fantasies
– strong preference for playmates of the opposite
sex
GID cont.
Persistent discomfort with his or her sex or
sense of inappropriateness in the gender
role of that sex
 Boys:

– wishing that penis/testes would disappear
– aversion to stereotypical male play/toys

Girls
– rejection of female clothing, sitting to urinate
– assertion of not wanting breasts/menstruation
Transexualism
Cross gender identification and don’t
receive sexual excitement by cross dressing
 Rare

– Men: 1 in 40,000 to 1 in 100,000
– Women: 1 in 100,000 to 1 in 400,000

Most are scorned and victimized in
childhood leading to high rates of suicide,
antisocial behavior and self-mutilation
Transsexual Surgery
Programs
Long term period of evaluation and
preparation (usually 2-4 years)
 Goal is adjustment once the decision is
made

–
–
–
–
Intensive psychotherapy
hormone therapy
trails of cross dressing
surgery
Paraphillia Questions

What is the total # of behaviors in a week
that culminate in orgasm?
– Only 5% of the population have >7.
Paraphilliacs have 7 or more.

What are the different ways that you
become aroused to the point of orgasm?
Sexual Abuse Victims
(Holmes & Sapp, 2003)

Underreported, under recognized and under
treated.
– Prevalence estimates 4-76%

Boys with highest risk
–
–
–
–


< 13;
Nonwhite
Low SES
Not living with fathers
Need for cleared definitions, better sampling
methods, more sophisticated data analysis
HCP need to be more aware and sensitive
Sexual Abuse-Women
Also under: reported, recognized & Tx’d
 Associated with increased risk for:

–
–
–
–
–
Unintended 1st pregnancy
Physical abuse (victim & perpetrator)
Psychiatric disorder
Substance dependence
Suicide attempt
Pedophiles



Most frequent Axis I d/o’s-MDE, substance abuse*
(ETOH-”big disinhibitor”) “proximal risk”
Exhibitionism is impulsive, most others are
planned (Avg. Pedophile has committed >30 acts
before caught)
Almost always males-Heterosexual males are 2x
as common as homosexual (Myth-homosexuals
are more likely to abuse)
Pediophilles cont.
Most are mild-mannered, innocuous
appearing men with profound feelings of
inadequacy and low self-esteem
 Failed relationships with women
 Many were sexually abused as children
“remote risk”

Treatment of Pedeophilles

Cog-beh/Beh-including shock, or other aversion
therapies paired with the presentation of the
previously arousing stimuli. Recently “castration”
– disordered sexual arousal
– maximize “normal” arousal
– teach assertiveness training and sex education

Very high rate of recidivism (Hanson & Harris,
2000); Need better coordination with CJ system
– Anger, subjective distress, attitudes of tolerance of
abuse, poor self management, poor social supports and
substance abuse