Transcript Comer, Abnormal Psychology, 5th edition

Chapter 13
Sexual Disorders and Gender Identity
Disorder
Slides & Handouts by Karen Clay Rhines, Ph.D.
Seton Hall University
Sexual Disorders and
Gender Identity Disorder
 Sexual behavior is a major focus of both our private
thoughts and public discussions
 Experts recognize two general categories of sexual
disorders:
• Sexual dysfunctions – problems with sexual responses
• Paraphilias – sexual urges and fantasies in response to
socially inappropriate objects or situations
 The DSM also includes a diagnosis called gender
identity disorder, a sex-related disorder in which
people feel that they have been assigned to the
wrong sex
Slide 2
Sexual Dysfunctions
 Sexual dysfunctions are disorders in which people
cannot respond normally in key areas of sexual
functioning
• As many as 31% of men and 43% of women in the U.S.
suffer from such a dysfunction during their lives
 Sexual dysfunctions are typically very distressing,
and often lead to sexual frustration, guilt, loss of
self-esteem, and interpersonal problems
Slide 3
Sexual Dysfunctions
 The human sexual response can be described
as a cycle with four phases:
• Desire
• Excitement
• Orgasm
• Resolution
 Sexual dysfunctions affect one or more of the
first three phases
Slide 4
Slide 5
Slide 6
Sexual Dysfunctions
 Some people struggle with sexual dysfunction their
whole lives (labeled “lifelong type” in DSM-IV)
• For others, normal sexual functioning preceded the
disorder (labeled “acquired type”)
 In some cases the dysfunction is present during all
sexual situations (labeled “generalized type”)
• In others it is tied to particular situations (labeled
“situational type”)
Slide 7
Disorders of Desire
 Desire phase of the sexual response cycle
• Consists of an urge to have sex, sexual fantasies,
and sexual attraction to others
 Two dysfunctions affect this phase:
• Hypoactive sexual desire disorder
• Sexual aversion disorder
Slide 8
Disorders of Desire
 Hypoactive sexual desire disorder
• Characterized by a lack of interest in sex and a
low level of sexual activity
• Physical responses may be normal
• Prevalent in about 16% of men and 33% of
women
• DSM refers to “deficient” sexual interest/activity
but provides no definition of “deficient”
• In reality, this criterion is difficult to define
Slide 9
Disorders of Desire
 Sexual aversion disorder
• Characterized by a total aversion to (disgust of)
sex
• Sexual advances may sicken, repulse, or frighten
• This disorder seems to be rare in men and more
common in women
Slide 10
Disorders of Desire
 A person’s sex drive is determined by a
combination of biological, psychological, and
sociocultural factors, and any of these may
reduce sexual desire
 Most cases of low sexual desire or sexual
aversion are caused primarily by sociocultural
and psychological factors, but biological
conditions can also lower sex drive
significantly
Slide 11
Disorders of Desire
 Biological causes
• A number of hormones interact to produce sexual
desire and behavior
• Abnormalities in their activity can lower sex drive
• These hormones include prolactin, testosterone, and
estrogen for both men and women
• Sex drive can also be lowered by chronic illness,
some medications, some psychotropic drugs, and
a number of illegal drugs
Slide 12
Disorders of Desire
 Psychological causes
• A general increase in anxiety or anger may reduce
sexual desire in both women and men
• Fears, attitudes, and memories may contribute to
sexual dysfunction
• Certain psychological disorders, including
depression and obsessive-compulsive disorder,
may lead to sexual desire disorders
Slide 13
Disorders of Desire
 Sociocultural causes
• Attitudes, fears, and psychological disorders that
contribute to sexual desire disorders occur within a social
context
• Many sufferers of desire disorders are feeling situational pressures
• Examples: divorce, death, job stress, infertility, and/or
relationship difficulties
• Cultural standards can impact the development of these disorders
• The trauma of sexual molestation or assault is also likely to
produce sexual dysfunction
Slide 14
Disorders of Excitement
 Excitement phase of the sexual response cycle
• Marked by changes in the pelvic region, general physical
arousal, and increases in heart rate, muscle tension, blood
pressure, and rate of breathing
• In men: erection of the penis
• In women: clitoral swelling and vaginal lubrication
 Two dysfunctions affect this phase:
• Female sexual arousal disorder (formerly “frigidity”)
• Male erectile disorder (formerly “impotence”)
Slide 15
Disorders of Excitement
 Female sexual arousal disorder
• Characterized by repeated inability to maintain proper
lubrication or genital swelling during sexual activity
• Many with this disorder also have desire or orgasmic disorders
• It is estimated that more than 10% of women experience
this disorder
• Because this disorder is so often tied to an orgasmic
disorder, researchers usually study the two together;
causes of the two disorders will be examined together
Slide 16
Disorders of Excitement
 Male erectile disorder (ED)
• Characterized by repeated inability to attain or maintain
an adequate erection during sexual activity
• An estimated 10% of men experience this disorder
• Most are over the age of 50 years
• Many cases are associated with medical ailments or disease
• According to surveys, half of all adult men have erectile
difficulty during intercourse at least some of the time
Slide 17
Disorders of Excitement
 Most cases of erectile disorder result from an
interaction of biological, psychological, and
sociocultural processes
• Even minor physical impairment of the erection
response may make a man vulnerable to the
effects of psychosocial factors
Slide 18
Disorders of Excitement
 Biological causes
• The same hormonal imbalances that can cause
hypoactive sexual desire can also produce ED
• Most commonly, vascular problems are involved
• ED can also be caused by damage to the nervous
system from various diseases, disorders, or injuries
• The use of certain medications and substances
may interfere with erections
Slide 19
Disorders of Excitement
 Biological causes
• Medical devices have been developed for
diagnosing biological causes of ED
• One strategy involves measuring nocturnal penile
tumescence (NPT)
• Men typically have erections during REM sleep; abnormal or
absent nighttime erections usually indicate a physical basis
for erectile failure
Slide 20
Disorders of Excitement
 Psychological causes
• Any of the psychological causes of hypoactive sexual
desire can also interfere with erectile function
• For example, as many as 90% of men with severe depression
experience some degree of ED
• One well-supported cognitive explanation for ED
emphasizes performance anxiety and the spectator role
• Once a man begins to have erectile difficulties, he becomes
fearful and worried during sexual encounters; instead of being a
participant, he becomes a spectator and judge
• This can create a vicious cycle of sexual dysfunction where
the original cause of the erectile failure becomes less
important than the fear of failure
Slide 21
Disorders of Excitement
 Sociocultural causes
• Each of the sociocultural factors tied to
hypoactive sexual desire has also been linked to
ED
• Job and marital distress are particularly relevant
Slide 22
Disorders of Orgasm
 Orgasm phase of the sexual response cycle
• Sexual pleasure peaks and sexual tension is released as the
muscles in the pelvic region contract rhythmically
• For men: semen is ejaculated
• For women: the outer third of the vaginal walls contract
 There are three disorders of this phase:
• Premature ejaculation
• Male orgasmic disorder
• Female orgasmic disorder
Slide 23
Disorders of Orgasm
 Premature ejaculation
• Characterized by persistent reaching of orgasm and
ejaculation with little sexual stimulation
• About 30% of men experience premature ejaculation at some time
• Psychological, particularly behavioral, explanations of
this disorder have received more research support than
other theories
• The dysfunction seems to be typical of young, sexually
inexperienced men
• It may also be related to anxiety, hurried masturbation
experiences, or poor recognition of arousal
Slide 24
Disorders of Orgasm
 Male orgasmic disorder
• Characterized by a repeated inability to reach
orgasm or by a very delayed orgasm after normal
sexual excitement
• Occurs in 8% of the male population
• Biological causes include low testosterone,
neurological disease, and head or spinal injury
• Medications, including certain antidepressants
(especially SSRIs) and drugs that slow down the CNS,
can also affect ejaculation
Slide 25
Disorders of Orgasm
 Male orgasmic disorder
• A leading psychological cause appears to be
performance anxiety and the spectator role, the
cognitive factors involved in ED
Slide 26
Disorders of Orgasm
 Female orgasmic disorder
• Characterized by persistent delay in or absence of orgasm
following normal sexual excitement
• Almost 25% of women appear to have this problem
• 10% or more have never reached orgasm
• An additional 10% reach orgasm only rarely
• Women who are more sexually assertive and more comfortable
with masturbation tend to have orgasms more regularly
• Female orgasmic disorder appears more common in single women
than in married or cohabiting women
Slide 27
Disorders of Orgasm
 Female orgasmic disorder
• Most clinicians agree that orgasm during intercourse is not
mandatory for normal sexual functioning
• Early psychoanalytic theory used to consider lack of orgasm
during intercourse to be pathological
• Typically linked to female sexual arousal disorder
• The two disorders tend to be studied and treated together
• Once again, biological, psychological, and sociocultural
factors may combine to produce these disorders
Slide 28
Disorders of Orgasm
 Female orgasmic disorder
• Biological causes
• A variety of medical conditions can affect a woman’s arousal and
orgasm
• These conditions include diabetes and multiple sclerosis
• The same medications and illegal substances that affect erection
in men can affect arousal and orgasm in women
• For example, as many as 40% of women who take Prozac
and other SSRIs may have problems with orgasm or arousal
• Postmenopausal changes may also be responsible
Slide 29
Disorders of Orgasm
 Female orgasmic disorder
• Psychological causes
• The psychological causes of hypoactive sexual desire
and sexual aversion may also lead to female arousal
and orgasmic disorders
• Memories of childhood trauma and relationship
distress may also be related
Slide 30
Disorders of Orgasm
 Female orgasmic disorder
• Sociocultural causes
• For decades, the leading sociocultural theory of female
sexual dysfunction was that it resulted from sexually
restrictive cultural messages
• This theory has been challenged because:
• Sexually restrictive histories are equally common in women
with and without disorders
• Cultural messages about female sexuality have been changing
while the rate of female sexual dysfunction stays constant
Slide 31
Disorders of Orgasm
 Female orgasmic disorder
• Sociocultural causes
• Researchers suggest that unusually stressful events,
traumas, or relationships may produce the fears,
memories, and attitudes that characterize these
dysfunctions
• Research has also linked certain qualities in a woman’s
intimate relationships (such as emotional intimacy) to
orgasmic behavior
Slide 32
Disorders of Sexual Pain
 Two sexual dysfunctions do not fit neatly into
a specific phase of the sexual response cycle
• These are the sexual pain disorders:
• Vaginismus
• Dyspareunia
Slide 33
Disorders of Sexual Pain
 Vaginismus
• Characterized by involuntary contractions of the
muscles of the outer third of the vagina
• Severe cases can prevent a woman from having
intercourse
• Perhaps 20% of women occasionally have pain during
intercourse, but less than 1% of all women have
vaginismus
Slide 34
Disorders of Sexual Pain
 Vaginismus
• Most clinicians agree with the cognitive-behavioral theory
that vaginismus is a learned fear response
• A variety of factors can set the stage for this fear, including
anxiety and ignorance about intercourse, trauma caused by an
unskilled partner, and childhood sexual abuse
• Some women experience painful intercourse because of
infection or disease, leading to “rational” vaginismus
• Most women with vaginismus also have other sexual
disorders
Slide 35
Disorders of Sexual Pain
 Dyspareunia
• Characterized by severe pain in the genitals during sexual
activity
• Affects almost 15% of women and about 3% of men
• Dyspareunia in women usually has a physical cause, most
commonly from injury sustained in childbirth
• Although relationship problems or psychological trauma
from abuse may contribute to dyspareunia, psychosocial
factors alone are rarely responsible
Slide 36
Treatments for Sexual Dysfunctions
 The last 35 years have brought major changes
in the treatment of sexual dysfunction
• Early 20th century: psychodynamic therapy
• Believed that sexual dysfunction was caused by a
failure to negotiate the stages of psychosexual
development
• Therapy focused on gaining insight and making broad
personality changes; was generally unhelpful
Slide 37
Treatments for Sexual Dysfunctions
 1950s and 1960s: behavioral therapy
• Behavioral therapists attempted to reduce fear by
applying relaxation training and systematic
desensitization
• Had moderate success, but failed to work in cases
where the key problems were cognitive or
psychoeducational
Slide 38
Treatments for Sexual Dysfunctions
 1970: Human Sexual Inadequacy
• This book, written by William Masters and
Virginia Johnson, revolutionized treatment of
sexual dysfunctions
• This original “sex therapy” program has evolved
into a complex, multidimensional approach
• Includes techniques from cognitive, behavioral,
couples, and family systems therapies
• More recently, biological interventions have also been
incorporated
Slide 39
What Are the General
Features of Sex Therapy?
 Modern sex therapy is short-term and
instructive
• Therapy typically lasts 15 to 20 sessions
• It is centered on specific sexual problems rather
than on broad personality issues
Slide 40
What Are the General
Features of Sex Therapy?
 Modern sex therapy includes:
• Assessing and conceptualizing the problem
• Assigning “mutual responsibility” for the problem
• Education about sexuality
• Attitude change
• Elimination of performance anxiety and the spectator role
• Increasing sexual communication skills
• Changing destructive lifestyles and marital interventions
• Addressing physical and medical factors
Slide 41
What Techniques Are Applied
to Particular Dysfunctions?
 In addition to the universal components of sex
therapy, specific techniques can help in each
of the sexual dysfunctions
Slide 42
What Techniques Are Applied
to Particular Dysfunctions?
 Hypoactive sexual desire and sexual aversion
• These disorders are among the most difficult to
treat because of the many issues that feed into
them
• Therapists typically apply a combination of
techniques which may include:
• Affectual awareness, self-instruction training,
behavioral techniques, insight-oriented exercises, and
biological interventions such as hormone treatments
Slide 43
What Techniques Are Applied
to Particular Dysfunctions?
 Erectile disorder
• Treatments for ED focus on reducing a man’s
performance anxiety and/or increasing his stimulation
• May include sensate-focus exercises such as the “tease technique”
• Biological approaches, used when the ED has biological
causes, have gained great momentum with the recent
approval of sildenafil (Viagra)
• Most other biological approaches have been around for decades
and include gels, suppositories, penile injections, a vacuum
erection device (VED), and penile implant surgery
Slide 44
What Techniques Are Applied
to Particular Dysfunctions?
 Male orgasmic disorder
• Like treatment for ED, therapies for this disorder
include techniques to reduce performance anxiety
and increase stimulation
• When the cause of the disorder is physical,
treatment may include a drug to increase arousal
of the nervous system
Slide 45
What Techniques Are Applied
to Particular Dysfunctions?
 Premature ejaculation
• Premature ejaculation has been successfully treated for
years by behavioral procedures such as the “stop-start” or
“pause” technique
• Some clinicians favor the use of fluoxetine (Prozac) and
other serotonin-enhancing antidepressant drugs
• Because these drugs often reduce sexual arousal or orgasm, they
may be helpful in delaying premature ejaculation
• While some studies have reported positive findings, long-term
outcome studies have yet to be conducted
Slide 46
What Techniques Are Applied
to Particular Dysfunctions?
 Female arousal and orgasmic disorders
• Specific treatment techniques for these disorders include
self-exploration, enhancement of body awareness, and
directed masturbation training
• Again, a lack of orgasm during intercourse is not
necessarily a sexual dysfunction, provided the woman
enjoys intercourse and is orgasmic through other means
• For this reason, some therapists believe that the wisest course of
action is simply to educate women whose only concern is lack of
orgasm through intercourse
Slide 47
What Techniques Are Applied
to Particular Dysfunctions?
 Vaginismus
• Specific treatment for vaginismus takes two
approaches:
• Practice tightening and releasing the muscles of the
vagina to gain more voluntary control
• Overcome fear of intercourse through gradual
behavioral exposure treatment
• Over 75% of women treated for vaginismus using
these methods eventually report pain-free
intercourse
Slide 48
What Techniques Are Applied
to Particular Dysfunctions?
 Dyspareunia
• Determining the specific cause of dyspareunia is
the first stage of treatment
• Given that most cases are caused by physical
problems, medical intervention may be necessary
Slide 49
What Are the Current Trends
in Sex Therapy?
 Over the past 30 years, sex therapists have
moved beyond the approach first developed
by Masters and Johnson
• Therapists now treat unmarried couples, those
with other psychological disorders, couples with
severe marital discord, the elderly, the medically
ill, the physically handicapped, clients with a
homosexual orientation, and clients with no longterm sex partner
Slide 50
What Are the Current Trends
in Sex Therapy?
 Therapists are paying more attention to
excessive sexuality, which is sometimes
called sexual addiction
 The use of medications to treat sexual
dysfunction is troubling to many therapists
• They are concerned that therapists will choose
biological interventions rather than a more
integrated approach
Slide 51
Paraphilias
 These disorders are characterized by unusual
fantasies and sexual urges or behaviors that
are recurrent and sexually arousing
• Often involve:
• Humiliation of self or partner
• Children
• Nonconsenting people
• Nonhuman objects
Slide 52
Paraphilias
 According to the DSM, paraphilias should be
diagnosed only when the urges, fantasies, or
behaviors last at least 6 months
• For most paraphilias, the urges, fantasies, or
behaviors must also cause great distress or
impairment
• For certain paraphilias, however, performance of the
behavior itself is indicative of a disorder
• Example: sexual contact with children
Slide 53
Paraphilias
 Some people with one kind of paraphilia display
others as well
• Relatively few people receive a formal diagnosis, but
clinicians believe that the patterns may be quite common
 Although theorists have proposed various
explanations for paraphilias, there is little formal
evidence to support the theories
• None of the treatments applied to paraphilias have
received much research or proved clearly effective
• Recent work has focused on biological interventions
Slide 54
Fetishism
 The key features of fetishism are recurrent
intense sexual urges, sexually arousing
fantasies, or behaviors that involve the use of
a nonliving object
• The disorder usually begins in adolescence
• Almost anything can be a fetish
• Women’s underwear, shoes, and boots are especially
common
Slide 55
Fetishism
 Researchers have been unable to pinpoint the
causes of fetishism
• Psychodynamic theorists view fetishes as defense
mechanisms, but therapy using this model has
been unsuccessful
Slide 56
Fetishism
 Behaviorists propose that fetishes are learned
through classical conditioning
• Fetishes are sometimes treated with aversion therapy,
covert sensitization, or imaginal exposure
• Another behavioral treatment is masturbatory satiation, in
which clients masturbate to boredom while imagining the
fetish object
• An additional behavioral treatment is orgasmic
reorientation, a process which teaches individuals to
respond to more appropriate sources of sexual stimulation
Slide 57
Transvestic Fetishism
 Also known as transvestism or cross-dressing
 Characterized by fantasies, urges, or
behaviors involving dressing in the clothes of
the opposite sex in order to achieve sexual
arousal
Slide 58
Transvestic Fetishism
 The typical person with transvestism is a
heterosexual male who began cross-dressing
in childhood or adolescence
 Transvestism is often confused with gender
identity disorder (transsexualism), but the two
are separate patterns
 The development of the disorder seems to
follow the behavioral principles of operant
conditioning
Slide 59
Exhibitionism
 Characterized by arousal from the exposure of
genitals in a public setting
• Also known as “flashing”
• Sexual contact is neither initiated nor desired
 Usually begins before age 18
 Treatment generally includes aversion therapy and
masturbatory satiation
• May be combined with orgasmic reorientation, social
skills training, or psychodynamic therapy
Slide 60
Voyeurism
 Characterized by repeated and intense sexual
desires to observe people in secret as they
undress or to spy on couples having
intercourse; may involve acting upon these
desires
• The person may masturbate during the act of
observing or while remembering it later
• The risk of discovery often adds to the excitement
Slide 61
Voyeurism
 Many psychodynamic theorists propose that
voyeurs are seeking power
• Others have explained it as an attempt to reduce
fears of castration
 Behaviorists explain voyeurism as a learned
behavior that can be traced to a chance and
secret observation of a sexually arousing
scene
Slide 62
Frotteurism
 A person who develops frotteurism has fantasies,
urges, or behaviors involving touching and rubbing
against a nonconsenting person
• Almost always male, the person fantasizes during the act
that he is having a caring relationship with the victim
 Usually begins in the teenage years or earlier
• Acts generally decrease and disappear after age 25
Slide 63
Pedophilia
 Characterized by fantasies, urges, or
behaviors involving sexual activity with a
prepubescent child, usually 13 years of age or
younger
• Some people are satisfied with child pornography
• Others are driven to watching, fondling, or
engaging in intercourse with children
• Victims may be male, but evidence suggests that
two-thirds are female
Slide 64
Pedophilia
 People with pedophilia develop the disorder
in adolescence
• Some were sexually abused as children
• Many were neglected, excessively punished, or
deprived of close relationships in childhood
• Most are immature, display faulty thinking, and
have an additional psychological disorder
• Some theorists have proposed a related biochemical or
brain structure abnormality
Slide 65
Pedophilia
 Most people with pedophilia are imprisoned
or forced into treatment
• Treatments include aversion therapy,
masturbatory satiation, and orgasmic reorientation
• Cognitive-behavioral treatment involves relapseprevention training, modeled after programs used
for substance dependence
Slide 66
Sexual Masochism
 Characterized by fantasies, urges, or
behaviors involving the act or thought of
being humiliated, beaten, bound, or otherwise
made to suffer
 Most masochistic fantasies begin in childhood
and seem to develop through the behavioral
process of classical conditioning
Slide 67
Sexual Sadism
 A person with sexual sadism finds fantasies,
urges, or behaviors involving the thought or
act of psychological or physical suffering of a
victim sexually exciting
• Named for the infamous Marquis de Sade
• People with sexual sadism imagine that they have
total control over a sexual victim
Slide 68
Sexual Sadism
 Sadistic fantasies may first appear in
childhood
• Pattern is long-term
• Appears to be related to classical conditioning
and/or modeling
 Psychodynamic and cognitive theorists view
people with sexual sadism as having
underlying feelings of sexual inadequacy
Slide 69
Sexual Sadism
 Biological studies have found possible
abnormalities in the endocrine system
 The primary treatment for this disorder is
aversion therapy
Slide 70
A Word of Caution
 The definitions of paraphilias, like those of
sexual dysfunctions, are strongly influenced
by the norms of the particular society in
which they occur
 Some clinicians argue that, except when
people are hurt by them, paraphilic behaviors
should not be considered disorders at all
Slide 71
Gender Identity Disorder
 Gender identity disorder, or transsexualism, is
one of the most fascinating disorders related
to sexuality
• People with this disorder persistently feel that
they have been assigned to the wrong biological
sex
• They would like to remove their primary and
secondary sex characteristics and acquire the
characteristics of the opposite sex
Slide 72
Gender Identity Disorder
 Men with GID outnumber women 2 to 1
 People with GID often experience anxiety or
depression and may have thoughts of suicide
Slide 73
Gender Identity Disorder
 People with gender identity disorder usually feel
uncomfortable wearing the clothes of their own sex
and may cross-dress
• This is distinctly different from a transsexual fetish; there
is no sexual arousal related to this disorder
 The disorder sometimes emerges in childhood and
disappears with adolescence
• In some cases it develops into adult gender identity
disorder
Slide 74
Gender Identity Disorder
 Several theories have been proposed to explain this
disorder, but research is limited and generally weak
• Some clinicians suspect biological factors
• Abnormalities in the hypothalamus (particularly the bed nucleus
of stria terminalis) are a potential link
 Some adults with this disorder change their sexual
characteristics by way of hormones; others opt for
sexual reassignment (sex-change) surgery
Slide 75