Sexual Dysfunctions

 Male hypoactive sexual desire disorder and female sexual 4. Orgasm Phase
interest/arousal disorder  Males – feelings of the inevitability of ejaculation, followed
 Erectile Disorder by ejaculation
 Pre-mature Ejaculation  Females – contractions of the walls of the lower third of the
 Delayed ejaculation/female orgasmic disorder vagina
 Genito-pelvic pain/penetration disorder 5. Resolution Phase – decrease in arousal occurs after orgasm,
particularly in men
Categories of Sexual Dysfunction Among Men and Women
 Some women do not enter resolution phase and instead
Type of Men Women continue to have sexual activity
Disorder
Male hypoactive sexual Specify if:
Female sexual
Desire desire disorder (little or  Lifelong – disturbance present since individual first became sexually
interest/arousal disorder
no desire to have sex) active
(little or no desire to have
Erectile disorder  Acquired – disturbance began after a period of relatively normal
sex)
Arousal (difficulty attaining or sexual function
maintaining erections)
o Can be from trauma
Delayed ejaculation; Female orgasmic disorder
Orgasm  Generalized – not limited to certain types of stimulation, situations,
premature ejaculation
or partners
Genito-pelvic
pain/penetration disorder  Situational – only occurs with certain types of stimulation,
(pain, anxiety, and tension situations, or partners
associated with sexual
Pain Specify current severity:
activity; vaginismus –
 Mild – evidence of mild distress
muscle spasms in the vagina
that interfere with  Moderate – evidence of moderate distress
penetration)  Severe – evidence of severe or extreme distress

NORMAL SEXUAL BEHAVIOR Male Hypoactive Sexual Desire DO & Female Sexual Interest/Arousal DO
1. Desire Phase – sexual urges occur in response to sexual cues or  Male Hypoactive Sexual Desire DO
fantasies o Persistent/recurrent absence of sexual desire (including
2. Arousal Stage – a subjective sense of sexual pleasure and thoughts and fantasies also urges)
physiological signs of sexual arousal  Judgments made by a clinician (based on self-
 Males: penile tumescence – increased flow into the penis report, observation, history)
 Females: vasocongestion – blood pools into the pelvic area o Minimum of 6 months
leading to vaginal lubrication and breast tumescence (erect o Causes distress
nipples) o Lifelong/acquired
3. Plateau Phase – brief period that occurs before orgasm o Generalized/situational
 o Problem is physical arousal (erection, lubrication, etc.)
 Most men with erectile disorder are over the age of 50
 Female Sexual Interest/Arousal DO
o Men typically have erections during REM sleep
o At least 3:
 Performance anxiety, financial stresses, marital stresses, and
 Absent/reduced interest in sexual activity, erotic
increased pressure to have an erection contribute to this problem
thought, and fantasies
 No or reduced initiation and unreceptive Pre-mature Ejaculation
 Absent/reduced sexual excitement and pleasure  Diagnostic Criteria:
during sex in almost all encounters o Persistent or recurrent pattern of ejaculation within
 Absent/reduced arousal in internal and external approximately 1 minute during sex following vaginal
cues penetration and before individual wishes it
 Absent/reduced genital or non-genital sensations o Minimum of 6 months
o Minimum 6 months and causes distress  Must be experienced on almost all encounters
o May be lifelong/acquired o Causes distress
o Generalized/situational o May be lifelong/acquired
 Difficult to assess low sexual desire o May be generalized/situational
o Great clinical judgment is needed  Most common orgasmic disorder among males
o Must differentiate if the lowered sexual desire is due to  May affect men at ANY age
another disorder (ex. depression)  Common among young, sexually inexperienced men, who has not
 Even though there is reduced interest, when engaging in sex physical learned to slow down, control arousal, and extend the process of
experiences may be normal and there may be enjoyment in the making love
experience in some cases  A perceived lack of control over one’s orgasm is a major determinant
 Patients with these disorders tend not to have sexual fantasies,
seldom masturbate, and attempt intercourse once a month or less Delayed Ejaculation/Female Orgasmic DO
 Male
Erectile DO o Marked delay in ejaculation
 Diagnostic Criteria: o Infrequency/absence of ejaculation
o At least one of the following: o Minimum of 6 months
 Difficulty obtaining erection during sex o Causes distress
 Difficulty maintaining an erection until completion o May be lifelong/acquired
 Decrease in erectile rigidity o May be generalized/situational
o Minimum of 6 months, causes distress  Female
o May be lifelong/acquired o Marked delay/infrequency/absence of orgasm
o May be generalized/situational o Minimum of 6 months
 The problem is not desire o Causes distress
o Most have frequent sexual urges and strong desire to have o May be lifelong/acquired
sex o May be generalized/situational
  Definition of “delay” does not have precise boundaries, no
consensus as to what constitutes a reasonable time to reach orgasm
or what is unacceptably long for most men and their sexual partners
 Low testosterone level, certain neurological diseases, and some
head or spinal cord injuries can interfere with ejaculation
 Alcohol and other substances slowing down the sympathetic
nervous system (depressants) affects ejaculation
 Unmarried women are more likely to experience this disorder
 Men seldom seek treatment for delayed ejaculation
o More for premature ejaculation
Genito-Pelvic Pain/Penetration DO
 Malock ang penis and vagina
 Common among those who experienced sexual abuse
 Diagnostic Criteria:
o Difficulties with one or more of the following:
 Vaginal penetration during sex
 Vulvovaginal or pelvic pain during sex or penetration
attempts
 Fear or anxiety about pain in anticipation or as a
result of penetration
 Tensing or tightening of pelvic floor muscles during
attempted penetration
o Minimum of 6 months, causes distress
o May be lifelong/acquired
o May be generalized/situational
 Severe anxiety or panic attacks may occur in anticipation of possible
pain during intercourse
o Muscles around the pelvic floor spasm (vaginismus)
o Outer third of the vagina contracts preventing entry of penis
 May be a learned fear response due to an expectation that
intercourse is painful and damaging
o Factors that set the stage for fear:
 Anxiety and ignorance about intercourse
 Exaggerated stories about how painful first times
could be
 Inexperienced lover who forces the penis before the
woman is aroused
 Trauma of childhood sexual abuse or adult rape
 Other Causes
o Biological
 Diabetes, kidney disease, vascular disease, coronary
artery disease, prescription medications (e.g.,
antihypertensive medications, SSRIs, anxiolytics,
etc.), alcohol
o Psychological
 Distractions by non-sexual stimulus
 Not mentally present during sexual activity
 Expecting the worst
 Negative thoughts during sexual activity
 Little to no awareness of arousal state
o Sociocultural
 Associating sexual cues with negative affect (sex
guilt, sex myths)
 Early traumatic sexual events
 Deterioration in close interpersonal relationships
 Perception that one is less attractive
Treatments
 Sexual education
 Removing psychological performance anxiety
 Sensate focus and non-demand pleasuring
 Training in masturbatory procedures (use of sex toys,
communications, etc)
 Squeeze technique (males with premature ejaculation)
 Viagra, testosterone shots, papaverine/prostaglandin, vacuum
device therapy, etc.

Gender Dysphoria
 Children
o Marked incongruence between one’s experienced/
expressed gender and assigned gender (at least 6 months)
as manifested by at least six of the following (one of which
must be Criterion 1):
 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
 In boys (assigned gender), a strong preference for
crossdressing or simulating female attire; OR in girls
(assigned gender), a strong preference for wearing
only typical masculine clothing and a strong
resistance to the wearing of typical feminine
clothing
 Strong preference for cross-gender roles in make-
believe play or fantasy play
 Strong preference for the toys, games, or activities
stereotypically used or engaged in by the other
gender
 Strong preference for playmates of the other gender
 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
 Strong dislike of one’s sexual anatomy
 Strong desire for the primary and/or secondary sex
characteristics that match one’s experienced gender
o Clinically significant distress or impairment in social, school,
or other important areas of functioning
o Specify if:
 With a disorder of sex development (congenital
adrenogenital DO, congenital adrenal hyperplasia,
androgen insensitivity syndrome)
 Adolescence and Adults
o Marked incongruence between one’s experienced/
expressed gender and assigned gender (at least 6 months)
as manifested by at least two of the following:
 A marked incongruence between one’s
experienced/expressed gender and primary and/or
secondary sex characteristics
 Young adolescents – anticipated secondary
sex characteristics
 Strong desire to be rid of one’s primary and/or
secondary sex characteristics because of a marked
incongruence with one’s experienced/expressed
gender
 Young adolescents – desire to prevent
development of the anticipated secondary
sex characteristics
 Strong desire for the primary and/or secondary sex
characteristics of the other gender
 Strong desire to be of the other gender (or some
alternative gender different from one’s assigned
gender)
 Strong desire to be treated as the other gender (or
some alternative gender different from one’s
assigned gender)
 Strong conviction that one has the typical feelings
and reactions of the other gender (or some
alternative gender different from one’s assigned
gender)
o Clinically significant distress or impairment in social,
occupational, or other important areas of functioning
o Specify if:
  With a disorder of sex development (congenital
adrenogenital DO, congenital adrenal hyperplasia,
androgen insensitivity syndrome)
 Posttransition – individual transitioned to full-time
living in desired gender and has undergone (or
preparing to have) at least one cross-sex medication
procedure or treatment regimen
 Many want to remove primary and secondary sex characteristics
o May find genitals repugnant
 Children may develop this disorder but in most cases the pattern
Exhibitionistic DO
disappears by adolescence or adulthood
o Adults with this disorder may have had a childhood form of
gender dysphoria
 May be largely biological in nature and may run in families
o Heightened blood flow in the insula and reduced blood flow
in the anterior cingulate cortex (areas related to sexuality
and consciousness)
Paraphilic Disorders
 Sexual deviance (ways to get aroused)
 Seldom seen in women
Voyeuristic DO
 “Peeping tom”
 Fantasies about voyeurism (imagination) but has not acted upon it –
voyeuristic sexual interests
 Must have action to be considered a disorder
 Power play – gaining power over an unsuspecting person
 Diagnostic Criteria:
o Recurring and intense sexual arousal from observing an
unsuspecting person who is naked, disrobing, or doing sex
as manifested by fantasies, urges, or behaviors (min. 6
months)
o Acted on these urges with a non-consenting person or
sexual urges/fantasies
o Causes significant distress
o At least 18 years of age
 May masturbate during the act of observing or when thinking about
it afterward
o Sex with the person being spied on is not the goal
 Vulnerability of people being observed, and possible humiliation is
part of the enjoyment of the voyeur
o Risk of being discovered adds to excitement
 This might be a manifestation of trying to gain power over others or
a learned behavior traced from chance encounters with sexually
arousing scenes
 Wanting to shock or leave an impression on others. Sex with other
person is not the goal
 Also involves power play
 Fantasizing about it – exhibitionistic sexual interest
 More shocked victim = more arousal
 Diagnostic Criteria:
o Recurring and intense sexual arousal from exposure to one’s
genitals to an unsuspecting person as manifested by
fantasies, urges, or behaviors (min. 6 months)
o Acted on these sexual urges with a non-consenting person
 Urges or fantasies cause significant distress
o Specify whether:
 Exposed genitals to pre-pubertal children
 Exposed genitals to physically mature individuals
 Both
 Most often, shock or surprise is what the person wants rather than
initiate sexual activity
o Sometimes expose themselves in particular neighborhoods
(crowded) at particular (peak) hours
 Typically immature in their dealings with the opposite sex and have
difficulty in interpersonal relationships
o Thrill of risk is important
 May have doubts about their masculinity
o Prove the size of the genitals and feed their ego
 Some may have a strong bond to possessive mothers
 o Controlling mom  response is to flash as a form of
rebellion
Frotteuristic DO
 Fantasized about it – frotteuristic sexual fantasy
 Diagnostic Criteria:
o Recurring and intense sexual arousal from touching or
rubbing against a non-consenting person as manifested by
fantasies, urges, or behaviors (min. 6 months)
o Acted on these urges with a non-consenting individual
 Urges causes distress
 Usually committed in crowded place or a busy sidewalk
 May rub genitals against victim’s thighs/buttocks or fondle genital
area or breasts of others
 Fantasies of having a caring/intimate relationship with the victim
Sexual Masochism/Sadism DO
 No distress/harm involved = masochistic/sadistic orientation, not DO
 Some may deny sadistic tendencies but fit the diagnostic criteria
 Not acting upon fantasies – does not qualify for the disorder
 Roleplay is common (BDSM), observable through porn they watch
 More common among males, may develop pre-puberty -
adolescence
 Diagnostic Criteria:
o Over 6 months, recurrent and intense sexual arousal from
the act of being humiliated, beaten, bound, or otherwise
made to suffer as manifested by fantasies/urges
(masochism)
 Specify if: with asphyxiophilia – achieving sexual
arousal related to restriction of breathing
o Over 6 months, recurrent, and intense sexual arousal from
physical or psychological suffering of another person as
manifested by fantasies/urges (sadism)
o Causes significant distress or impairment
 Masochism – may fantasize about being raped or perhaps act on the
urges themselves by tying, sticking pins into themselves, or cutting
themselves (does not need other people)
o Some engage in hypoxyphilia (asphyxiophilia)
 Sadism – may fantasize about dominating, restraining, blindfolding,
cutting, etc.
o Imagine having total control over a sexual victim
 Both may arouse out of classical conditioning
Pedophilic DO
 Indicator of pedophilia –child pornography
 May deny tendencies
 Diagnostic Criteria:
o Over 6 months, recurrent and intense sexual fantasies,
urges, or behaviors involving sexual activities with a
prepubescent child or children (generally 13 years and
younger)
o Individual has acted on sexual urges, or these
urges/fantasies cause distress
o Individual at least 16 years and at least 5 years older than
the child or children
o NOTE: Do not include individual in late adolescence involve
in an ongoing sexual relationship with a 12- or 13-year-old
o Specify whether:
 Exclusive type – attracted to only children
 Nonexclusive type – attracted to both adults and
children
o Specify if:
 Sexually attracted to males, females, or both
 Limited to incest
 May be satisfied with child pornography or even innocent ads
regarding children
o May start to manifest during puberty or adolescence
  Theory: rejection by peers leads to seeking comfort
in younger people
 Often immature with social/sexual skills being underdeveloped with
thoughts of normal sexual relationships fill them with anxiety
 May have a history of being sexually abused as a child, neglect,
being excessively punished, or being deprived of close relationships
 Be careful with diagnosis esp. during periods of sexual exploration
(min. 16 years old)
 Usually loners, may become child molesters (may not use force, but
instead “love bomb” or shower child with love and care)
o Conditions child to think it’s their fault they were abused
 Appears to be lifelong but elements may change over time
o Distress, psychosocial impairment, act out sexually with children
or adults
Fetishistic DO
 May include specific stimulations from objects (ex. feeling of rubber
on skin)
 Can be called partialism (specific body part)
 Requires distress or impairment – without these it’s just a fetish
 Diagnostic Criteria:
o Over 6 months, recurrent and intense sexual arousal from
either the use of nonliving objects or a highly specific focus
on non-genital body parts
 Specify if: body part, non-living object, or animal
o Fantasies/urges cause distress or impairment
o Not limited to items used in cross-dressing or devices used
for the purpose of genital stimulation
 Far more common in men than women
o Almost anything can be a fetish: women’s underwear, shoes,
hair, foot, etc.
o Some steal to acquire object of fetish
 Objects may be touched, smelled, worn, or use in some other way
while the person masturbates
o Person may ask partner to wear object during sex
 Fetishes may be defense mechanisms or may be acquired through
classical conditioning
 Multisensory experience – holding, tasting, rubbing, inserting,
smelling, letting partner wear object, collection of desired fetishes
Transvestic DO
 Usually males crossdressing
 Commonly enter “macho” organizations (ex. army)
 Diagnostic Criteria:
o Over 6 months, recurrent and intense sexual arousal from
cross-dressing as manifested by fantasies/urges
o Cause distress or impairment
o Specify if:
 With fetishism – sexually aroused by fabrics,
materials, garments
 With autogynephilia – sexually aroused by thoughts
or images of self as female
 May begin cross-dressing in childhood or adolescence
o Diminishing sexual response, instead feel comfortable with
the clothes
o Tendencies may disappear when entering first sexual
relationship
 May develop out of early childhood rewards such as encouragement
from parents or other adults
 Some may wear single items of clothing while others go fully
dressed
TREATMENTS
 Antiandrogens – “chemical castration”
o Eliminates sexual desire and fantasy by reducing
testosterone levels dramatically
 Aversion Therapy – associate unpleasurable experience with
imagination of sexual object
 Orgasmic reorientation/reconditioning – masturbate with usual
sexual fantasies then substitute them with desirable ones before
ejaculating
 Covert sensitization – practice guided imagery and associate images
of children, clothes with reason why behavior is harmful or
dangerous
 o Shifts the desires and cues
 Cognitive-behavioral therapy
 Relapse prevention training