Sexual Disorders and Paraphilias

Most personal area of life.

Each of us is sexual being with preferences and
fantasies that may surprise or even shock us from time
to time.
Usually these are part of normal sexual functioning.
But when our fantasies or desire begin to affect or other
in unwanted or harmful ways, they begin to qualify as
abnormal.
 Gender and Sexuality
• Across wide range of indices, men reported more engagement
in sexual thought and behavior that do women.
• Compared to women, men report thinking about sex,
masturbation, and desiring sex more often, as well as desiring
more sexual partner and having more partners.
• Beyond these differences in sex drive Peplau (2003) has
described several other ways in which the genders tend to
differ in sexuality. Women tend to be more ashamed of any
flaws in their appearance than the men, and this shame can
interfere with sexual satisfaction (Sanchez & Kiefer, 2007)
 Gender and Sexuality
• For women, sexual appears more closely tied to
relationship status and social norms that for men
(Baumeister, 200).
• Among women with sexual symptoms, more than
half believe their symptoms are caused by
relationship problems (Nicholls, 2008).
• Men are more likely to think about their sexuality in
terms of power than are women (Andersen, et al.
1999).
 Gender and Sexuality
There are many parallels in men’s and women’s
sexuality. For example, in a survey more than 1,000
women reported that their primary motivation for
having sex was sexual attraction and physical
gratification (Meston & Buss, 2009) It would be
exaggeration to claim that the sole reason women are
having sex is to promote relationship closeness. It is
important to acknowledge commonalities as well as
differences across genders.
 Sexual Response Cycle
Many researchers have focused on understanding the
sexual response cycle. Kinsey group made
breakthroughs in the 1940’s by interviewing people
about sexuality. Masters and Johnson created another
revolution in research on human sexuality 50 years ago
when they began to gather direct observations and
physiological measurements of people masturbating
and having sexual intercourse.
 Sexual Response Cycle
Kaplan identified four phases in the human sexual response
cycle.
1. Desire phase. This stage refers to sexual interest or desire,
often associated with sexually arousing fantasies or
thoughts.
2. Excitement phase. During this phase, men and women
experience pleasure and increased blood flow to the
genitalia.
3. Orgasm Phase. Sexual pleasure peaks in ways that have
fantasies poets and rest of us ordinary people for thousand
years.
4. Resolution phase. This last stage refers to the relaxation
and sense of well-being that usually follow an orgasm.
 Sexual Dysfunctions
 Sexual dysfunctions are disorders in which people
cannot respond normally in key areas of sexual
functioning
 Sexual dysfunctions are typically very distressing,
and often lead to sexual frustration, guilt, loss of
self- esteem, and interpersonal problems
 Clinical Description
DSM – 5 divides sexual dysfunctions into three
categories:
Those involving: 1) sexual desire, arousal and interest;

2) orgasmic disorder; and 3) sexual pain disorders.

The diagnostic criteria for all sexual dysfunctions
specify that dysfunction should be persistent and
recurrent and should cause clinically significant distress
or problems functioning
Sexual Interest, Desire and
Arousal
• Sexual interest/arousal disorder in women.
Refers to persistent deficits in sexual interest
(sexual fantasies or urges), biological arousal or
subjective arousal.
• Hypoactive sexual desire disorder in men.
Refers to deficient or absent sexual fantasies
and urges, and erectile disorder refers to failure
to attain or maintain an erection through
completion of the sexual activity.
 Orgasmic Disorders
• Female orgasmic disorder. Refers to the
persistent absence of orgasm after sexual
excitement.
Two orgasmic disorder for men:
• Early ejaculation disorder. Defined by
ejaculation that occurs too quickly.
• Delayed ejaculation disorder. Define by
persistent difficulty in ejaculating.
 Sexual Pain Disorder
• Genito-pelvic pain/penetration disorder. Defined by
persistent or recurrent pain during intercourse.

• DSM ndistinguished two pain disorders:

 Dyspareunia is define by persistent or recurrent pain
during sexual intercourse.
 Vaginismus is define by involuntary muscle spasms
of outer third of the vagina to a degree that make
intercourse impossible.
 Parapahilia
• Paraphilias or perversions are sexual stimuli or acts that are
deviations from normal sexual behaviors, but are necessary
for some persons to experience arousal and orgasm.
• These individuals can experience sexual pleasure, but are
inhibited from responding to stimuli that are normally
considered erotic.
• The paraphiliac's sexuality is restricted to specific deviant
stimuli or acts. Persons that occasionally experiment with
paraphiliac behavior (e.g., infrequent episode of bondage or
dressing in costumes), but are capable of responding to more
typical erotic stimuli, are not diagnosed as suffering from
paraphilias.
 Diagnosis and Clinical Features

• In DSM the diagnostic criteria for paraphilias include

the presence of a pathognomonic fantasy and an
intense urge to act out the fantasy or its behavior
elaboration.
• The fantasy, which may distress a patient, contains
unusual sexual material that is relatively fixed and
shows only minor variations.
• Arousal and orgasm depend on the mental elaboration
or the behavioral playing out of the fantasy. Sexual
activity is ritualized or stereotyped and makes use of
degraded, reduced, or dehumanized objects.
 Exhibitionism
• Exhibitionism is the recurrent urge to expose
the genitals to a stranger or to an unsuspecting
person.
• Sexual excitement occurs in anticipation of the
exposure, and orgasm is brought about by
masturbation during or after the event.
 Fetishism

• In fetishism the sexual focus is on objects

(e.g., shoes, gloves, pantyhose, and
stockings) that are intimately associated
with the human body.
 Frotteurism
• Frotteurism is usually characterized
by a man's rubbing against the
buttocks or other body parts of a
fully clothed woman to achieve
orgasm.
 Pedophilia
• Pedophilia involves recurrent intense sexual urges
toward, or arousal by, children 13 years of age or
younger, over a period of at least 6 months.
• Persons with pedophilia are at least 16 years of age
and at least 5 years older than the victims
• Most child molestations involve genital fondling or oral
sex.
• Vaginal or anal penetration of children occurs
infrequently, except in cases of incest.
• Most child victims coming to public attention are girls
 Sexual Masochism
–Sexual arousal in response to being
humiliated, bound, or beaten, for at least 6
months and suffer impairment, the arousal
must be in response to actual, not
simulated humiliation, bondage, or
beatings
–Most sexual masochists use little or no
pain, more so through the loss of control
–Can lead to serious injury and death
(especially in the case of hypoxyphilia)
–20:1 males: females
 Sexual Sadism
• According to psychoanalytic
theory, sadism is a defense against fears of
castration; persons with sexual sadism do to
others what they fear will happen to them and
derive pleasure from expressing their
aggressive instincts.
• The onset of the disorder is usually before the
age of 18 years, and most persons with sexual
sadism are male.
 Voyeurism (scopophilia)
• It is the recurrent preoccupation with
fantasies and acts that involve observing
persons who are naked or engaged in
grooming or sexual activity
 Transvestic Fetishism

• Transvestic fetishism is described as fantasies

and sexual urges to dress in opposite gender
clothing as a means of arousal and as an
adjunct to masturbation or coitus.
• As years pass, some men with transvestic
fetishism want to dress and live permanently
as women. More rarely, women want to dress
and live as men.
 Paraphilia Not Otherwise Specified

• Telephone scatologia is characterized by obscene

phone calling and involves an unsuspecting partner.
• Tension and arousal begin in anticipation of phoning;
the recipient of the call listens while the telephoner
(usually male) verbally exposes his preoccupations or
induces her to talk about her sexual activity.
• The conversation is accompanied by masturbation,
which is often completed after the contact is
interrupted.
• Persons also use interactive computer networks,
sometimes compulsively, to send obscene
messages by electronic mail and to transmit
sexually explicit messages and video images.
• Because of the anonymity of the users in chat
rooms who use aliases, on-line or computer sex
(cybersex) allows some persons to play the role of
the opposite sex, which represents an alternative
method of expressing transvestic or transsexual
fantasies.
 Necrophilia
• Necrophilia is an obsession with obtaining
sexual gratification from cadavers.
 Partialism

• Persons with the disorder of partialism

concentrate their sexual activity on one part
of the body to the exclusion of all others.
 Zoophilia
• Sexual relations with animals may occasionally be
an outgrowth of availability or convenience,
especially in parts of the world where rigid
convention precludes premarital sexuality and in
situations of enforced isolation.
• Because masturbation is also available in such
situations, however, a predilection for animal
contact is probably present in opportunistic
zoophilia.
 Coprophilia and Klismaphilia

• Coprophilia is sexual pleasure associated with

the desire to defecate on a partner, to be
defecated on, or to eat feces (coprophagia).
• These paraphilias are associated with fixation
at the anal stage of psychosexual
development.
• Similarly, klismaphilia, the use of enemas as
part of sexual stimulation, is related to anal
fixation.
 Urophilia

• A form of urethral eroticism, is interest in

sexual pleasure associated with the desire to
urinate on a partner or to be urinated on.
• In both men and women, the disorder may
be associated with masturbatory techniques
involving the insertion of foreign objects into
the urethra for sexual stimulation.
 Masturbation

• Masturbation is a normal activity that is common

in all stages of life from infancy to old age, but
this viewpoint was not always accepted
• The techniques of masturbation vary in both
sexes and among persons.
• The most common technique is direct stimulation
of the clitoris or penis
• Indirect stimulation can also be used, such as
rubbing against an object
 Hypoxyphilia

• Hypoxyphilia is the desire to achieve an

altered state of consciousness secondary to
hypoxia while experiencing orgasm.
• Persons may use a drug (e.g., a volatile nitrite
or nitrous oxide) to produce hypoxia.
• Autoerotic asphyxiation is also associated with
hypoxic states, but it should be classified as a
form of sexual masochism.
 Differential Diagnosis

• Clinicians must differentiate a paraphilia from an

experimental act that is not recurrent or
compulsive and that is done for its novelty.
Paraphiliac activity most likely begins during
adolescence.
• Some paraphilias (especially the bizarre types)
are associated with other mental disorders, such
as schizophrenia.
• Brain diseases can also release perverse impulses.
 Course and Prognosis

• The difficulty in controlling or curing paraphilias rests

in the fact that it is hard for people to give up sexual
pleasure with no assurance that new routes to sexual
gratification will be secured.
• A poor prognosis for paraphilias is associated with an
early age of onset, a high frequency of acts, no guilt or
shame about the act, and substance abuse.
• The course and the prognosis are better when patients
have a history of coitus in addition to the paraphilia
and when they are self-referred rather than referred by a
legal agency.
 Treatment

 Restriction
 Treating comorbid conditions
 CBT
 Dynamic Psychotherapy
 Sex Addiction and Compulsivity

• The concept of sex addiction refers to persons

who compulsively seek out sexual experiences
and whose behavior becomes impaired if they
are unable to gratify their sexual impulses.
• Don Juanism (satyriasis):Some men who appear to be
hypersexual, as manifested by their need to have
many sexual encounters or conquests, use their
sexual activities to mask deep feelings of inferiority.
• Some have unconscious homosexual impulses, which
they deny by compulsive sexual contacts with
women.
• After having sex, most Don Juans are no longer
interested in the woman.
• Nymphomania: Nymphomania signifies a woman's
excessive or pathological desire for coitus.
 Persistent and Marked Distress about
Sexual Orientation

• Distress about sexual orientation is characterized

by dissatisfaction with sexual arousal patterns
and it is usually applied to dissatisfaction with
homosexual arousal patterns, a desire to increase
heterosexual arousal, and strong negative feelings
about being homosexual.
• Treatment : controversial, but psychoanalytic
therapy, Behavior therapy and avoidance
conditioning techniques can be helpful.