SEXUAL DISORDER

Prepared by:
AINI NADHIRAH BINTI HASHIM
NOR SYAKIRA BINTI OMAR
NUR FARIZAH BINTI ZUHAIDI
SEX RESPONSE CYCLE

Refractory
Period
Phase 4:
Resolution
Phase 3:
Orgasm
Phase 2:
Excitement/
Phase 1: Arousal
Desire
SEX RESPONSE CYCLE
• Desire: It is characterized by sexual fantasies and the conscious desire to have sexual activity.
• Excitement/arousal: Fantasy or physical contact (psychological, physiological stimulation)
 Erections, testicular enlargement, vaginal lubrication, clitoral erection, labial swelling, elevation of
uterus (tenting)
 Flushing, nipple erection, increased respiration, pulse, blood pressure

• Orgasm
 Men: Tightening of scrotal sac, secretion of few drops of seminal fluid  Ejaculation
 Women: Contraction of the outer 1/3 of vagina, enlargement of upper 1/3 of vagina  Contractions
of uterus and lower 1/3 of vagina
 Facial grimacing, release of tension, slight clouding of consciousness, involuntary anal sphincter
contractions, acute increase in blood pressure and pulse
• Resolution: Muscles relax and cardiovascular state returns to baseline, detumescence of genitalia
• Refractory period:
 Men: Minutes-Hours
 Women: Little or no RP
 SEXUAL
DYSFUNCTION
“Heterogeneous group of disorders that are typically characterized by a clinically significant
disturbance in a person's ability to respond sexually or to experience sexual pleasure.”

Male hypoactive sexual Female sexual interest/

Erectile disorder
desire disorder arousal disorder

Premature (early) Genito-pelvic pain/

Delayed ejaculation
ejaculation penetration disorder
CASE 1
• Mr. E, 30 years old married gentleman was brought to your clinic by his wife
because of problems in sexual intercourse. They had been married for 5 years.
She was unsatisfied and stated that they had no intercourse for the last 9
months and he rarely respond when she initiate any kind of sexual activities.
She was starting to suspect that Mr. E is cheating on her.
• He was a very successful IT manager who prides himself on being a good
problem-solver. However, Mr. E was very reluctant and embarrassed to seek
help. He looked very miserable.
• He is a straight man and anti-gay. He opened up and said that he had been
orally stimulated to orgasm by a male cousin, who was 7 years older, at age of
12 years old.
MALE HYPOACTIVE SEXUAL
DESIRE DISORDER
• Absence or deficiency of sexual thoughts,
desire or fantasies for >6 months.
• Prevalence: Persistent lack of interest in
sex, lasting 6 months or more, affects only
a small proportion of men ages 16-44
(1.8%).
• Comorbidity: Depression and other mental
disorders, endocrine diseases
• Risk factors:
 Psychological Factors: Depression and
anxiety.
 Physical Factors: Andropause
 Biological Factors: Heavy cigarette
smoking, alcoholism, diseases of the
vascular or nervous system.
 Psychosocial Factors: Early childhood
sexual abuse, relationship issues, stress,
and exhaustion.
 Medical Factors: Prostate removal, pelvic
radiation, spinal cord lesion, erectile
dysfunction.
MALE HYPOACTIVE SEXUAL
DESIRE DISORDER
A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts or fantasies and desire for sexual activity.

B. Persisted for a minimum duration of approximately 6 months.

C. Cause clinically significant distress in the individual.

D. Not better explained by a nonsexual mental disorder/consequence of severe relationship distress/other

significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

Specify whether:

• Lifelong/ Acquired

• Generalized/ Situational (limited to certain types of stimulation, situations, or partners)

Specify current severity:

• Mild: Evidence of mild distress

• Moderate: Evidence of moderate distress

• Severe: Evidence of severe or extreme distress

CASE 2
• Jenny, 41 years old housewife complains of having low sexual desire since the
birth of her children, who are now 8 and 10 years old. She describes her
marriage as “fine.” The children are not causing problems, and her husband,
Bob, is a good father and a considerate person.
• Jenny is not clinically depressed, has no history of depression and takes no
medications. Her general health is fine, with regular periods.
• Jenny denies any spontaneous sexual thinking, need to masturbate or having
anything other than the very occasional sexual dream. None of this has
changed throughout her adult life. She does not fantasize about anything —
sexual or otherwise. She confirms she does not have spontaneous sexual
wanting, which is the reason she is asking for help.
FEMALE SEXUAL
INTEREST/AROUSAL DISORDER
• Absence or reduced sexual interest, thoughts or fantasies, initiation of sex, sexual
excitement/pleasure, sexual arousal, and/or genital/non-genital sensations during sex for
>6 months
• Risk and prognostic factor: Temperamental, environmental, genetic and physiological
• Comorbidity: other sexual difficulties, sexual distress and dissatisfaction with sex life,
depression, thyroid problems, anxiety, urinary incontinence, and other medical factors.
• Arthritis and inflammatory or irritable bowel disease are also associated with sexual
arousal problems. Low desire appears to be comorbid with depression, sexual and
physical abuse in adulthood, global mental functioning, and use of alcohol.
FEMALE SEXUAL
INTEREST/AROUSAL DISORDER
A. Lack of, or significantly reduced, sexual
interest/arousal, as manifested by at least 3 of the
following:
 Interest in sexual activity.
 Sexual/erotic thoughts or fantasies.
 Initiation of sexual activity, and typically
unreceptive to a partner’s attempts to initiate.
 Sexual excitement/pleasure during sexual
activity in almost all or all sexual encounters.
 Sexual interest/arousal in response to any
internal or external sexual/ erotic cues.
 Genital or non-genital sensations during sexual
activity in almost all or all sexual encounters.
B. Persisted for a minimum duration of
approximately 6 months.
C. Cause clinically significant distress in the
individual.
D. 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.
• Specify whether:
 Lifelong/ Acquired
 Generalized/ Situational (limited to certain
types of stimulation, situations, or partners)
• Specify current severity:
 Mild: Evidence of mild distress
 Moderate: Evidence of moderate distress
 Severe: Evidence of severe or extreme distress
Differential Diagnosis
• Dyspareunia
• Inadequate lubrication
• Pelvic inflammatory disease
Treatment for Sexual Desire
Disorders
• Psychotherapy
 Education regarding on normal sexual response
 How to optimize the body’s sexual response
 Ways to enhance intimacy with partners
 Recommendations for reading materials

• Eros Clitoral Therapy Device, vacuum device

• Lubricant, vaginal moisturizers
• Pharmacotherapy
 Hormonal therapy: oestrogen (post-menopausal)
 Flibanserin is indicated for acquired, generalized HSDD in premenopausal women
 Antidepressant drugs, if the individual has depression or anxiety
CASE 3
• Mr. R is a 56-year-old man who presents to his family physician for follow-up
of hypertension control. During his history, he reports significant difficulty in
obtaining erection that has progressed over the past 8 months. This has been
distressing to him and to his wife and has caused significant marital strife. He
looked miserable and had low self-esteem.
• He has been treated for hypertension for 4 to 5 years and is currently taking a
combination of hydrochlorothiazide and atenolol with good blood pressure
control. His history includes obesity and a sedentary lifestyle.
• He reports no morning erections, nocturnal erections, or spontaneous erections
satisfactory for vaginal penetration. He has normal ejaculatory function
without postejaculatory pain.
ERECTILE DISORDER/ ERECTILE
DYSFUNCTION/ IMPOTENCE
• Marked difficulty obtaining or maintaining an erection, or marked decrease in erectile rigidity
>6months.
• Lifelong or acquired. May present as man with:
 Low self-esteem and a decreased sense of masculinity, depressed.
 Fear and/or avoidance of future sexual encounters.
 Decreased sexual satisfaction and reduced sexual desire in the individual's partner.

• Prevalence: increase in prevalence and incidence of erection problems particularly after age 50
years.
• Risk and Prognostic Factors: Depression, post-traumatic stress disorder. Risk factors for acquired
erectile disorder include age, smoking tobacco, lack of physical exercise, diabetes, and decreased
desire.
ERECTILE DISORDER
• Causes:
 Psychological: Fatigue, stress, relationship problems, anxiety
 Physical: Heart disease, DM, obesity, drugs, neurologic disease, cavernosal disorders,
multiple sclerosis, Parkinson’s disease
• Comorbidity: Premature ejaculation, male hypoactive sexual desire disorder, anxiety,
depression, dyslipidaemia, CVS disease, hypogonadism, multiple sclerosis, diabetes
mellitus, other vascular, neurological or endocrine disease
• Common in men with lower urinary tract symptoms related to prostatic hypertrophy
ERECTILE DISORDER
A. At least one of the three following symptoms
must be experienced on almost all or all
(approximately 75%-100%) occasions of sexual
activity:
• Marked difficulty in obtaining an erection during
sexual activity.
• Marked difficulty in maintaining an erection until
the completion of sexual activity.
• Marked decrease in erectile rigidity.
B. Persisted for a minimum duration of
approximately 6 months.
C. Cause clinically significant distress in the
individual.
D. 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.
Specify whether:
• Lifelong/ Acquired
• Generalized/ Situational (limited to certain types
of stimulation, situations, or partners)
Specify current severity:
• Mild: Evidence of mild distress
• Moderate: Evidence of moderate distress
• Severe: Evidence of severe or extreme distress
ERECTILE DISORDER
Differential Diagnosis Investigations
• Abdominal Vascular Injuries • Hormonal blood study: Testosterone (HPG
axis)
• Depression
• Hemoglobin A1c
• Hypogonadism
• Lipid profile
• Hypopituitarism (Panhypopituitarism)
• Noncoronary Atherosclerosis
• Type 2 Diabetes Mellitus
ED: Treatment
1. Treat underlying psychological/physical cause
 Dose reduction, drug holidays, adjunctive medication, and switching to another drug:
Risperidone  Olanzapine

2. Pharmacological treatment Phosphodiesterase-5 inhibitors

 Sildenafil (Viagra)
 Tadalafil (Cialis)
 Vardenefil (Levitra, Staxyn)
 Avanafil (Stendra)

3. Androgen therapy

4. If patient do not response to oral medication

 Penis pumps
 Penile implants
 Blood vessels surgery/ Intracavernosal injection of vasodilators
CASE 4
• David, a 24 year old, healthy male, who seemed a little shy and withdrawn.
• Patient said that he’s not sure whether he had a problem or not. He only had
one girlfriend before and they would do sexual intercourse once or twice per
week, purely by his initiation. After breaking up due to that reason, he had a
new girlfriend, Jane.
• He said that the intercourse was very short but Jane was understanding
although disappointed. Unfortunately, it happened consistently for about 8
months and he could sense Jane’s frustrations.
• They tried treating the problem using various products available online but
they only helped initially but not effective anymore.
PREMATURE EJACULATION
• Recurrent pattern of ejaculation during sex within 1 minute and before the individual
wishes it for >6 months.
• Prevalence: Increase with age.
• Risk and Prognostic factors: temperamental, genetic and physiological
• Causes: anxiety regarding the sex act, unconscious fears about the vagina, negative
cultural conditioning, embarrassing places, inexperienced (resolve with time), stressful
marriage
• Comorbidity: Erectile problems, certain anxiety disorders (lifelong), prostatitis, thyroid
disease, or drug withdrawal (acquired).
PREMATURE EJACULATION
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 it.
B. At least 6 months and must be experienced on
almost all or all (approximately 75%-100%)
occasions of sexual activity.
C. Causes clinically significant distress in the
individual.
D. 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
Specify whether:
• Lifelong/ Acquired
• Generalized/ Situational (limited to certain types
of stimulation, situations, or partners)
Specify current severity:
• Mild: Ejaculation within approximately 30
seconds to 1 minute of vaginal penetration.
• Moderate: Ejaculation within approximately 15-
30 seconds of vaginal penetration.
• Severe: Ejaculation occurring prior to sexual
activity, at the start of sexual activity, or within
approximately 15 seconds of vaginal penetration
Treatment
Differential Diagnosis Treatments
• Delayed orgasm in partner • Squeezing technique

• Psychotropic drug use • Start-and-stop technique

• SSRIs useful for treating premature ejaculation
• Chronic prostatitis include the following:
 Sertraline
 Paroxetine
 Fluoxetine
Investigations  Citalopram
• Serum testosterone (free and total) level  Dapoxetine
and the prolactin level • Desensitizing medications
 Simple combinations of lidocaine cream or related
topical anesthetic agents.
 A metered-dose lidocaine-prilocaine cutaneous spray
(Fortacin) is approved in Europe.
Case 5: Delayed ejaculation
 A couple presented with the man as the identified patient.
 He was unable to ejaculate during the intercourse. He always had difficulty in reaching climax, except in
rare circumstances. He ejaculated once when he was with two women at the same time and once when he
was experimenting with cocaine. He currently was not using any substances except for a moderate use of
alcohol.
 This patient was actually committed to his marriage, although he had extramarital sexual experiences. He did
not ejaculate with coitus in those situations either, although he could climax with oral sex.
 He stated he was more interested in the “conquest” than in the sex itself. He could climax with masturbation,
although he rarely masturbated himself, but went to massage parlors. He had issues with anger at women and
considered his wife to be excessively critical.
 He had difficulty doing any of the exercises that require him to pleasure his wife. His difficulty in giving
also made it hard for him to enjoy mutual pleasuring. It was easier for him to be the recipient of stimulation.
Points/ problem

 unable to ejaculate during the intercourse.

 had difficulty in reaching climax
 He did not ejaculate with coitus in those situations either, although he could climax with oral sex.
DELAYED EJACULATION

 Difficulty or inability to ejaculate despite the presence of adequate sexual stimulation and the desire to
ejaculate
 What happened is either the individual:
 Cannot ejaculate at all
 Only able to ejaculate with certain partner/ in certain situations
 Only able to ejaculate during masturbation
 Prevalence: Relatively constant until around age 50 years, when the incidence begins to increase
significantly
 Risk and Prognostic Factors: Genetic and physiological.
 Comorbidity: More common in severe forms of MDD
DELAYED EJACULATION

A. Either of the following symptoms must be experienced on almost all or all occasions (approximately 75%-
100%) of partnered sexual activity and without the individual desiring delay:
 Marked delay in ejaculation.
 Marked infrequency or absence of ejaculation.
B. Persisted for a minimum duration of approximately 6 months.
C. Cause clinically significant distress in the individual.
D. 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.
 DELAYED EJACULATION
 RULE OUT :
 Physical causes:
 Birth defect that impair the ejaculation
process  Medication
 Diabetic neuropathy  Antidepressants

 Heart disease that affects blood pressure  Antipsychotics

to the pelvic region  Antihypertensive
 Prostate or urinary tract infections  Diuretic
 hypertension  Alcohol
 Psychological causes
 Anxiety/ Depression
 Cultural/ Religious taboo
 Post traumatic experience
INVESTIGATION

 History and physical examination

 Examination of genitalia
 Lab test:
 Full blood count
 Glucose level
 Hormone level
 Kidney function
Treatments for Delayed Ejaculation

 Identify and treat the underlying cause first

 Psychotherapy , Behavioural therapy
 Supportive therapy/ Counselling
 Marital session
 Sex therapy
 Pharmacological treatment: Cyproheptadine (Periactin)/ Amantadine (Symmetrel)
Case 6: Genito-pelvic pain/ penetration
disorder

 Miss D was a 27 year old single woman who presented for therapy because of inability o have intercourse,
She described episodes with a recent boyfriend in which he had tried vaginal penetration but had been
unable to enter.
 The boyfriend did not have erectile dysfunction. Miss D experienced desire and able to achieve orgasm
through manual or oral stimulation. For almost a year, she and her boyfriend had sex play without
intercourse. However, he complained increasingly about his frustration at the lack of coitus, which he had
enjoyed in previous relationship.
 Miss D had a conscious fear of penetration and dreaded going to gynaecologist, although she was able to use
tampon when she menstruated.
Points/ problem

 His boyfriend had tried vaginal penetration but had been unable to enter.
 Miss D had a conscious fear of penetration, although she was able to use tampon when she menstruated.
GENITO-PELVIC PAIN/PENETRATION
DISORDER

Genito-pelvic pain/penetration disorder refers to four commonly comorbid symptom dimensions (one or
more):
 1) difficulty having intercourse
 2) genito-pelvic pain
 3) fear of pain or vaginal penetration
 4) tension of the pelvic floor muscles

Previously diagnosed as dyspareunia or vaginismus.

A pain disorder should not be diagnosed when an organic basis for pain is found or when it is caused by a
lack of lubrication.
 Dyspareunia - recurrent or persistent genital pain occurring before, during, or after intercourse.
 Vaginismus - constriction of the outer third of the vagina due to involuntary pelvic floor muscle tightening or
spasm, interfering with penile insertion and intercourse.
GENITO-PELVIC PAIN/PENETRATION
DISORDER

 Risk and prognostic factor: Environmental, genetic and physiological

 Comorbidity: other sexual difficulties, relationship distress
 GENITO-PELVIC PAIN/PENETRATION
DISORDER
A. Persistent or recurrent difficulties with one (or more) of the following:
 Vaginal penetration during intercourse.
 Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
 Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal
penetration.
 Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
B. Persisted for a minimum duration of approximately 6 months.
C. Cause clinically significant distress in the individual.
D. Not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress or
other significant stressors and is not attributable to the effects of a substance/medication or another medical
condition.
Ddx

 Dyspareunia
 Vaginismus
 Vulvar vestibulitis
 Vaginal tear
 Infection : HPV, Herpes simplex virus, Pelvic inflammatory disease, endometritis
 cystitis
Investigation

 History and physical examination

 Examination of genitalia : tear, infection
 Lab test:
 Full blood count: infection
 Hormone level
 Kidney function
GENERAL TREATMENTS

 Dual-sex therapy
 Behaviour therapy
 Group therapy
 Integrated sex therapy
 Biological treatments
 Antidepressants, hormone therapy
 For vaginismus: Fingers  vaginal dilators
 Sensed focus
Case 7 : Pedophilic disorder

 A 60 year old married janitor had worked as a fourth grade school teacher for 25 years before he transferred
school districts and finally several years later mysteriously lost his second job. He was referred for help after
his family discovered that he had repeatedly fondled the genitals of his 4 and 6 year old granddaughters.
 A father of five who had not had sex with his wife for 30 years after strenuously objecting to her cigarette
smoking, he was generous, helpful, and cooperative with his children and grandchildren.
 Intellectually slow, he preferred comic books and had a charming manner of playing with young children ‘
like he was one himself’.
 By his estimate he had touched the buttocks and genitals of at least 300 girl students, thinking only of how
they did not know what he was doing because he was being affectionate and they were too young to realize
what happened.
 He loved the anticipation and excitement of this behaviour. His teaching career ended when parents
complained to a principal.
Pedophilia

 Pedophilia involves recurrent intense sexual urges toward, or arousal by, children 13 years of age or younger
 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 oral sex.
 Most of victim: girls
 Can also involved : exhibitionism, rape,voyeurism.
Case 8: exhibitionistic disorder

 A substance-abusing professional was finally able to attain sobriety at age 33 years. With this
accomplishment, he met a women and got married, began to work steadily for the first time in his life and
was able to impregnate his new wife.
 His preferred sexual activity had been masturbation in semi-public places. The patient had a strong sense
that his mother had always thought him to be inadequate, did not like to spend time with him and constantly
made negative comparisons between him and his ‘all boy’ younger brother.
 He recalled several times when his father had tried to explain his mother’s antipathy; “It is just one of those
things son: your mother does not seem to like you”. Without substance abuse, he gave up his exhibitionism,
but he quickly developed sexual incapacity with his wife and became addicted to phone sex.
Exhibitionism

 Exhibitionism is the recurrent urge to expose the genitals to a stranger or to an unsuspecting person.
 orgasm is brought about by masturbation during or after the event.
 Almost 100% of cases: men exposing themselves.
 To assert their masculinity by showing their penises and by watching the victim’s reaction: fright, surprise,
disgust.
SEXUAL MASOCHISM
CASE STUDY

– A 27 year-old women presented for an interview with the director of a course to

which she had applied and which she was eager to take. She appeared at the
interview in the company of a man whom she introduced to the director saying
“this is my lover”.
– When people asked about this unusual behavior during the interview, the applicant
stated that her companion had ordered her to bring him and make the introduction.
She further explained that she was part of a group that utilized sadomasochistic
techniques in their sexual play.
■ Sexual pleasure from being abused and dominated by women
■ Recurrent preoccupation with sexual urges and fantasies involving the act of being humiliated,
beaten, bound, suffer.
DSM-5
 At least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten,
bound, suffer, as manifested by fantasies, urges and behaviors.
 The fantasies, sexual urges or behaviors cause clinically significant distress or impairment in
social, occupational or other important function.

■ Specify if
– With asphyxiophillia: related to restriction of breathing
– In a controlled environment: living in institutional or other setting where opportunities to
engage in masochistic sexual behavior are restricted
– In full remission: no distress or impairment in social, occupational, or others at least 5 years
while in uncontrolled environment.
SEXUAL SADISM
■ Before age 18, male
■ Defense against fears of castration.
■ They will do to others what they fear about and derive pleasure after expressing their
aggressive instincts.
■ Many cases, patient underlying schizophrenia.
■ DSM-5
– At least 6 months, recurrent and intense sexual arousal from the physical or psychological
suffering of another person, as manifested by fantasies, urges or behaviour.
– The individual has acted on these sexual urges with nonconsenting person, or the sexual
urges/fantasies cause clinically significant distress or impairment in social, occupational,
other important functioning.

■ Specify if:
– In a controlled environment: living in institutional or other settings where to engage in
sadistic sexual behaviors are restricted.
– In full remission: has not acted in nonconsenting person, and there has been no
distress/impairment in social, occupational or other at least 5 years in uncontrolled
environment.
FETISHISTIC
 CASE STUDY
■ A 50 year-old man entered treatment with a chief complaint of erectile disorder experienced
primarily with his wife. He was suffering from a moderate depression that related to both his
marital issues and business problems. He had no erectile problems with other women in bars. In
bars, he can smoking, and women’s act of smoking a cigarette was necessary to his sexual
arousal.
■ His family history included an alcoholic mother and emotionally abusive father who was a chain
smoker. On family car trips, the father would smoke with closed windows. If the patient
complained of feeling nauseous, the father would tell him to “shut up”.
■ He recalled being very attracted to a Sunday school teacher who smoked when he was 6 years
old. He first smoked when he was 13, sneaking and hiding behind his house. His first cigarette
was one he stole from his mother.
■ Sexual focus is on objects that are intimately associated with the human body or on nongenital
body parts.
■ DSM-5
– At least 6 months, recurrent and intense sexual arousal from either the use of nonliving
objects or a highly specific focus on nongenital body parts, as manifested by fantasies,
urges or behaviors.
– The fantasies, sexual urges or behaviors cause clinically significant distress/impairment in
social, occupational or other important functioning.
– The fetish objects are not limited to articles of clothing used in cross-dressing or devices
specifically designed for the purposed of tactile genital stimulation.

■ Specify: Specify if:

– Body parts - In a controlled environment
- In full remission
– Nonliving objects
– other
TRANSVESTIC
■ Fantasies or sexual urges to dress in opposite gender clothing as means of arousal and as
an adjunct to masturbation or coitus.
■ DSM-5
– At least 6 months, recurrent and intense sexual arousal from cross-dressing, as
manifested by fantasies, urges or behaviors.
– The fantasies, sexual urges or behaviors cause clinically significant
distress/impairment in social, occupational or other important functioning.

■ Specify if:
– With fetishism: sexual aroused by fabrics, materials or garments
– With autogynephillia: sexual arousal by thoughts or images of self as female

■ Specify if:
– In a controlled environment
– In full remission
TREATMENT OF
PARAPHILIC
DISORDER
■ External control
– Prison
■ Reduction of sexual derives
– Antiandrogens
– Depo-provera
– Serotonergic agents
■ Treat the comorbid conditions
– Antipsychotic
– Antidepressant
■ Cognitive-behavioral therapy
– Social skill training
– Sex education
– Cognitive restructuring
– Development of victim empathy
■ Dynamic psychotherapy
– Insight-oriented psychotherapy