SEXUAL AND GENDER ISSUES

SEXUAL DYSFUNCTIONS,
PARAPHILIAS AND GENDER
DYSPHORIA
BY GEOFRY OUMA

Phases of response cycle:
• Desire – affected by personal, social, cultural, hypothalamic and hormonal
factors.
• Arousal – excitement, mediated by parasympathetic nervous system.
Genital vasoconstriction leads to erection in male or swelling and lubrication
in female.
• Plateau – maintenance of arousal state.
• Orgasm – emission, in male only. Ejaculation or, in female, ejaculatory
equivalent. Both mediated by sympathetic nervous system.
• Resolution – with a longer refractory period in the male (can be 24 hours if
over 60 years) and very short refractory period in the female (allowing for
multiple orgasms).

NEUROPHYSIOLOGY
Exact mechanism of orgasm unknown.
• Dopaminergic effects result in increased sexual activity.
Antidopaminergic drugs cause decreased sexuality and impotence.
• Noradrenergic effects ( alpha 2 receptors) reduce sexual activity.

Sexuality
Sexuality consists of four interrelated psychosexual factors: sexual identity,
gender identity, sexual orientation, and sexual behavior.
 Sexual identity is the pattern of a person’s biologic sexual characteristics.
 Gender identity is a person’s sense of maleness or femaleness and is
believed to be determined primarily by chromosomes and hormones and
secondarily affected by one’s environment.
 Sexual orientation: How one views one’s self in terms of being emotionally,
romantically, sexually, or affectionately attracted to an individual of a
particular gender.
 Sexual behavior: How one responds to sexual impulses and desires.

-Gender role is the external manifestation of being masculine,
feminine, or androgynous in a social context. It represents what
society expects of each sex and thus to some extent is ﬂuid across time
and among cultures.

Sexual dysfunctions
- Sexual dysfunctions are conditions in which the sexual response cycle is
disturbed or there is pain during coitus. Within this category are the
- sexual desire disorders and sexual arousal disorders e.g. female sexual
interest/arousal disorder, male hypoactive sexual desire disorder and
erectile dysfunction.
-orgasmic disorders such as female orgasmic disorders, delayed and
premature ejaculation.
-sexual pain disorders/Genito-pelvic pain disorders- such as non-organic
dyspareunia and vaginismus.
Miscellaneous such as substance/medication induced sexual dysfunction.

Female Sexual Interest/Arousal Disorder
-This disorder is characterized by a reduced or absent interest or
pleasure in sexual activity (APA, 2013).
-The individual typically does not initiate sexual activity, and is
commonly unreceptive to partner’s attempts to initiate.
-There is an absence of sexual thoughts or fantasies, and absent or
reduced arousal in response to sexual or erotic cues.
-The condition has persisted for at least 6 months and causes the
individual significant distress.

DSM 5 DIAGNOSTIC CRITERIA
A. Lack of, or significantly reduced, sexual interest/arousal, as manifested by at
least three of the following:
1. Absent/reduced interest in sexual activity.
2. Absent/reduced sexual/erotic thoughts or fantasies.
3. No/reduced initiation of sexual activity, and typically unreceptive to a partner’s attempts to
initiate.
4. Absent/reduced sexual excitement/pleasure during sexual activity in almost
all or all (approximately 75%–100%) sexual encounters (in identified situational contexts or, if
generalized, in all contexts).
5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues
(e.g., written, verbal, visual).
6. Absent/reduced genital or non-genital sensations during sexual activity in almost all or all
(approximately 75%–100%) sexual encounters (in identified situational contexts or, if generalized, in
all contexts).

B. The symptoms in Criterion A have persisted for a minimum
duration of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in
the individual.
D. The sexual dysfunction is not better explained by a nonsexual
mental disorder or as a consequence of severe relationship distress
(e.g., partner violence) or other significant stressors and is not
attributable to the effects of a substance/medication or another
medical condition.

MALE HYPOACTIVE SEXUAL DESIRE DISORDER
• This disorder is defined by the DSM-5 as a persistent or recurrent
deficiency or absence of sexual fantasies and desire for sexual activity.
• In making the judgment of deficiency or absence, the clinician
considers factors that affect sexual functioning, such as age and
circumstances of the person’s life (APA, 2013).
• The condition has persisted for at least 6 months and causes the

DIAGNOSTIC DSM 5 CRITERIA
A. Persistently or recurrently deficient (or absent) sexual/erotic thoughts
or fantasies and desire for sexual activity. The judgment of deficiency is made
by the clinician, taking into account factors that affect sexual functioning,
such as age and general and sociocultural contexts of the individual’s life.
B. The symptoms in Criterion A have persisted for a minimum duration
of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. The sexual dysfunction is 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.

ERECTILE DYSFUNCTION
-Erectile disorder is characterized by marked difficulty in obtaining or
maintaining an erection during sexual activity, or a decrease in erectile
rigidity that interferes with sexual activity (APA, 2013).
-The problem has persisted for at least 6 months and causes the
-Primary erectile disorder refers to cases in which the man has never
been able to have intercourse; secondary erectile disorder refers to
cases in which the man has difficulty getting or maintaining an erection
but has been able to have vaginal or anal intercourse at least once.

DSM-5 DIAGNOSTIC CRITERIA
A. At least one of the three following symptoms must be experienced on
almost all or all (approximately 75%–100%) occasions of sexual activity
(in identified situational contexts or, if generalized, in all contexts):
1. Marked difficulty in obtaining an erection during sexual activity.
2. Marked difficulty in maintaining an erection until the completion of
sexual activity.
3. Marked decrease in erectile rigidity.
B. The symptoms in Criterion A have persisted for a minimum duration
of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.

mental disorder or as a consequence of severe relationship distress or
other significant stressors and is not attributable to the effects of a

FEMALE ORGASMIC DISORDER
- Female orgasmic disorder is defined by the DSM-5 as a marked delay
in, infrequency of, or absence of orgasm during sexual activity
(APA, 2013).
- It may also be characterized by a reduced intensity of orgasmic
sensation.
- The condition, which is sometimes referred to as anorgasmia, has
lasted at least 6 months, and causes the individual significant distress.
- Women who can achieve orgasm through noncoital clitoral
stimulation but are not able to experience it during coitus in the
absence of manual clitoral stimulation are not necessarily categorized
as anorgasmic.

• A woman is considered to have primary orgasmic disorder when she
has never experienced orgasm by any kind of stimulation.
• Secondary orgasmic disorder exists if the woman has experienced at
least one orgasm, regardless of the means of stimulation, but no
longer does so.

A. Presence of either of the following symptoms and experienced on almost all or
all (approximately 75%–100%) occasions of sexual activity (in identified
situational contexts or, if generalized, in all contexts):
1. Marked delay in, marked infrequency of, or absence of orgasm.
2. Markedly reduced intensity of orgasmic sensations.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or
as a consequence of severe relationship distress (e.g., partner violence) or other

Delayed Ejaculation
• Delayed ejaculation is characterized by marked delay in ejaculation or
marked infrequency or absence of ejaculation during partnered sexual
activity (APA, 2013).
• The condition has lasted for at least 6 months and causes the individual
significant distress. With this disorder, the man is unable to ejaculate, even
though he has a firm erection and has had more than adequate
stimulation.
• The severity of the problem may range from only occasional problems
ejaculating (secondary disorder) to a history of never having experienced
an orgasm (primary disorder).
• In the most common version, the man cannot ejaculate during coitus but
may be able to ejaculate as a result of other types of stimulation.

A. Either of the following symptoms must be experienced on
almost all or all occasions (approximately 75%–100%) of
partnered sexual activity (in identified situational contexts or, if
generalized, in all contexts), and without the individual desiring
delay:
1. Marked delay in ejaculation.
2. Marked infrequency or absence of ejaculation.
B. The symptoms in Criterion A have persisted for a minimum
duration of approximately 6 months.

C. The symptoms in Criterion A cause clinically significant distress in
the individual.
mental disorder or as a consequence of severe relationship distress or
other significant stressors and is not attributable to the effects of a

Premature (Early) Ejaculation
- The DSM-5 describes premature (early) ejaculation as persistent or
recurrent ejaculation occurring within
1 minute of beginning partnered sexual activity and before the person
wishes it (APA, 2013).
-The condition has lasted at least 6 months and causes the individual
significant distress. The diagnosis should take into account factors that affect
the duration of the excitement phase, such as the person’s age, the
uniqueness of the sexual partner, and frequency of sexual activity (Sadock &
Sadock, 2007).
-Premature (early) ejaculation is the most common sexual disorder for which
men seek treatment. It is particularly common among young men who have
a very high sex drive and have not yet learned to control 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. The symptom in Criterion A must have been present for at least 6 months
and must be experienced on almost all or all (approximately 75%–100%)
occasions of sexual activity (in identified situational contexts or, if
generalized, in all contexts).
C. The symptom in Criterion A causes clinically significant distress in the
individual.
D. The sexual dysfunction is not better explained by a nonsexual mental
disorder or as a consequence of severe relationship distress or other

Genito-Pelvic Pain/Penetration Disorder
• Pain disorders include Dyspareunia and Vaginismus.
• These disorders present similarly, but while Vaginismus is solely a
female disorder, both males and females may experience
Dyspareunia.
• Those with dyspareunia experience significant genital pain during
intercourse, and also with insertion of tampons, fingers, or during
gynecological examinations. Both males and females can be affected
by dyspareunia, although more attention has been given to
dyspareunia in females.

• Similar to dyspareunia, those with vaginismus have difficulty with
vaginal penetration due to genital pain. The musculature surrounding
the vaginal opening is subject to spasms and hypertonicity, making
sexual intercourse virtually impossible. Women feel burning,
stretching, or tearing sensations around the vaginal opening, and
often experience an extreme level of fear regarding penetration.
• The condition may be lifelong (present since the individual became
sexually active) or acquired (began after a period of relatively normal
sexual function). It has persisted for at least 6 months and causes the
individual clinically significant distress.

A. Persistent or recurrent difficulties with one (or more) of the following:
1. Vaginal penetration during intercourse.
2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts.
3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during,
or as a result of vaginal penetration.
4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal
penetration.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the individual.
D. The sexual dysfunction is not better explained by a nonsexual mental disorder or as a
consequence of a severe relationship distress (e.g., partner violence) or other
significant stressors and is not attributable to the effects of a substance/medication
or another medical condition.

Substance/Medication-Induced Sexual
Dysfunction
• With these disorders, the sexual dysfunction developed after
substance intoxication or withdrawal or after exposure to a
medication (APA, 2013).
• The dysfunction may involve pain, impaired desire, impaired arousal,
or impaired orgasm.
• Some substances/medications that can interfere with sexual
functioning include alcohol, amphetamines, cocaine, opioids,
sedatives, hypnotics, anxiolytics, antidepressants, antipsychotics,
antihypertensives, and others.

A. A clinically significant disturbance in sexual function is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or
after exposure to or withdrawal from a
medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by a sexual dysfunction that is not substance/medication-
induced. Such evidence of an independent sexual dysfunction could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial
period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or
there is other evidence suggesting the existence of an independent non-substance/medication-induced
sexual dysfunction (e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress in the individual.

Predisposing Factors to Sexual Dysfunction
• Biological Factors
• Sexual Desire Disorders- Studies have correlated decreased levels of serum
testosterone with hypoactive sexual desire disorder in men. Evidence also
exists that suggests a relationship between higher serum testosterone
levels and increased female libido (Traish &Kim, 2006).
• Diminished libido has been observed in both men and women with
elevated levels of serum prolactin (Nappi, Ferdeghini, & Polatti, 2006).
• Various medications have also been implicated in the etiology of
hypoactive sexual desire disorder. Some examples include
antihypertensives, antipsychotics, antidepressants, anxiolytics, and
anticonvulsants. Alcohol and cocaine have also been associated with
impaired desire, especially after chronic use.

• Sexual Arousal Disorders Postmenopausal women require a longer period of stimulation
for lubrication to occur, and there is generally less vaginal transudate after menopause
(Altman & Hanfling, 2003).
• Various medications, particularly those with antihistaminic and anticholinergic
properties, may also contribute to decreased ability for arousal in women.
Arteriosclerosis is a common cause of male erectile disorder as a result of arterial
insufficiency (King, 2011).
• Various neurological disorders can contribute to erectile dysfunctions as well. The most
common neurologically based cause may be diabetes, which places men at high risk for
neuropathy (Kim & Brosman, 2013). Others include temporal lobe epilepsy and multiple
sclerosis.
• Trauma (e.g., spinal cord injury, pelvic cancer surgery) can also result in erectile disorder.
Several medications have been implicated in the etiology of this disorder, including
antihypertensives, antipsychotics, antidepressants, and anxiolytics.
• Chronic use of alcohol has also been shown to be a contributing factor.

• Orgasmic Disorders- Some women report decreased ability to achieve
orgasm following hysterectomy.
• Conversely, some report increased sexual activity and decreased sexual
dysfunction following hysterectomy (Rhodes, Kjerulff, Langenberg, &
Guzinski, 1999).
• Studies of the use of transdermal testosterone for sexual dysfunction in
women after hysterectomy have revealed mixed results (Nappi et al.,
2005).
• Some medications (e.g., selective serotonin reuptake inhibitors) may inhibit
orgasm.
• Medical conditions, such as depression, hypothyroidism, and diabetes
mellitus, may cause decreased sexual arousal and orgasm.

• Biological factors associated with delayed male orgasm include
surgery of the genitourinary tract (e.g., prostatectomy), various
neurological disorders (e.g., Parkinson’s disease), and other
diseases(e.g., diabetes mellitus).
• Medications that have been implicated include opioids,
antihypertensives, antidepressants, and antipsychotics (Altman &
Hanfling, 2003). Transient cases of the disorder may occur with
excessive alcohol intake.

• Although premature ejaculation is commonly caused by
psychological factors, general medical conditions or substance use
may also be contributing influences.
• Particularly in cases of secondary dysfunction, in which a man at one
time had ejaculatory control but later lost it, physical factors may be
involved.
• Examples include a local infection such as prostatitis or a
degenerative neural disorder such as multiple sclerosis.

• Sexual Pain Disorders- A number of organic factors can contribute to
painful intercourse in women, including intact hymen, episiotomy scar,
vaginal or urinary tract infection, ligament injuries, endometriosis, or
ovarian cysts or tumors.
• Painful intercourse in men may also be caused by various organic factors.
For example, infection caused by poor hygiene under the foreskin of an
uncircumcised man can cause pain.
• Phimosis, a condition in which the foreskin cannot be pulled back, can also
cause painful intercourse.
• An allergic reaction to various vaginal spermicides or irritation caused by
vaginal infections may be a contributing factor.
• Finally, various prostate problems may cause pain on ejaculation.

Psychological factors
• Sexual Desire Disorders- Phillips (2000) has identified a number of
individual and relationship factors that may contribute to hypoactive
sexual desire disorder.
• Individual causes include religious orthodoxy; sexual identity conflicts;
past sexual abuse; financial, family, or job problems; depression; and
aging-related concerns (e.g., changes in physical appearance).
• Among the relationship causes are interpersonal conflicts; current
physical, verbal, or sexual abuse; extramarital affairs; and desire or
practices that differ from those of the partner.

• Sexual Arousal Disorders- A number of psychological factors have
been cited as possible impediments to female arousal.
• They include doubt, guilt, fear, anxiety, shame, conflict,
embarrassment, tension, disgust, irritation, resentment, grief,
hostility toward partner, and a puritanical or moralistic upbringing.
• Sexual abuse has been identified as a significant risk factor for desire
and arousal disorders in women

• Problems with male sexual arousal may be related to chronic stress,
anxiety, or depression.
• Developmental factors that hinder the ability to be intimate, that lead to a
feeling of inadequacy or distrust, or that develop a sense of being unloving
or unlovable may also result in impotence.
• Relationship factors that may affect erectile functioning include lack of
attraction to one’s partner, anger toward one’s partner, or being in a
relationship that is not characterized by trust (Altman & Hanfling, 2003).
• Unfortunately, regardless of the etiology of the erectile dysfunction, once it
occurs, the man may become increasingly anxious about his next sexual
encounter. This anticipatory anxiety about achieving and maintaining an
erection may then perpetuate the problem.

• Orgasmic Disorders- Numerous psychological factors are associated with
inhibited female orgasm. They include fears of becoming pregnant or
damage to the vagina, rejection by the sexual partner, hostility toward
men, and feelings of guilt regarding sexual impulses (Sadock & Sadock,
2007).
• Negative cultural conditioning (“nice girls don’t enjoy sex”) may also
influence the adult female’s sexual response.
• Various developmental factors also have relevance to orgasmic
dysfunction. Examples include childhood exposure to rigid religious
orthodoxy, negative family attitudes toward nudity and sex, and traumatic
sexual experiences during childhood or adolescence, such as incest or rape
(Clayton, 2002; Phillips, 2000).

• Psychological factors are also associated with inhibited male orgasm
(delayed ejaculation).
• In the primary disorder (in which the man has never experienced
orgasm), the man often comes from a rigid, puritanical background.
He perceives sex as sinful and the genitals as dirty, and he may have
conscious or unconscious incest wishes and guilt (Sadock & Sadock,
2007).
• In the case of secondary disorder (previously experienced orgasms
that have now stopped), interpersonal difficulties are usually
implicated. There may be some ambivalence about commitment, fear
of pregnancy, or unexpressed hostility.

• Premature (early) ejaculation may be related to a lack of physical
awareness on the part of a sexually inexperienced man.
• The ability to control ejaculation occurs as a gradual maturing process
with a sexual partner in which foreplay becomes more give-and-take
“pleasuring,” rather than strictly goal-oriented.
• The man becomes aware of the sensations and learns to delay the
point of ejaculatory inevitability.
• Relationship problems such as a stressful marriage, negative cultural
conditioning, anxiety over intimacy, and lack of comfort in the sexual
relationship may also contribute to this disorder.

• Sexual Pain Disorders Penetration disorders may occur in response to having
experienced Genito-pelvic pain for various organic reasons stated in the “Biological
Factors” section.
• Involuntary constriction within the vagina occurs in response to anticipatory pain, making
intercourse impossible.
• The diagnosis does not apply if the etiology is determined to be due to another medical
condition.
• A variety of psychosocial factors have been implicated, including negative childhood
conditioning of sex as dirty, sinful, and shameful.
• Early traumatic sexual experiences (e.g., rape or incest) may also cause penetration
disorder.
• Other etiological factors that may be important include homosexual orientation,
traumatic experience with an early pelvic examination, pregnancy phobia, STD phobia, or
cancer phobia (Dreyfus, 2009; King, 2011; Leiblum, 1999; Phillips, 2000; Sadock &
Sadock, 2007).

• Transactional model of stress/adaptation which states that the
etiology of sexual dysfunction is most likely influenced by multiple
factors.

PARAPHILIAC DISORDERS
• Paraphilias are unusual sexual interests, such as voyeurism,
exhibitionism, pedophilia, fetishism, and sexual sadism and
masochism.
• The lines between sexual deviance and psychopathology are
complicated by the fact that there is no scientific answer to what is
considered “normal” sexual behavior. Many people who seek help for
a paraphilia are referred for treatment after a criminal sexual offense.

TYPES OF PARAPHILIC DISORDERS
• Exhibitionistic Disorder
• Fetishistic Disorder
• Frotteuristic Disorder
• Pedophilic Disorder
• Sexual Masochism Disorder
• Sexual Sadism Disorder
• Transvestic Disorder
• Voyeuristic Disorder

Exhibitionistic Disorder
• Exhibitionistic disorder is characterized by recurrent and intense sexual
arousal (manifested by fantasies, urges, or behaviors of at least 6 months’
duration) from the exposure of one’s genitals to an unsuspecting individual
(APA, 2013).
• Masturbation may occur during the exhibitionism. In most cases of
exhibitionism, the perpetrators are men and the victims are women (King,
2011).
• The urges for genital exposure intensify when the exhibitionist has
excessive free time or is under significant stress.
• Most people who engage in exhibitionism have rewarding sexual
relationships with adult partners but concomitantly expose themselves to
others.

A. Over a period of at least 6 months, recurrent and intense sexual
arousal from the exposure of one’s genitals to an unsuspecting
person, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant
distress or impairment in social, occupational, or other important areas
of functioning.

Fetishistic Disorder
• Fetishistic disorder involves recurrent and intense sexual arousal
(manifested by fantasies, urges, or behaviors of at least 6 months’
duration) from the use of either non-living objects or specific non-
genital body part(s) (APA, 2013).
• A common sexual focus is on objects intimately associated with the
human body (e.g., shoes, gloves, stockings).
• The fetish object is usually used during masturbation or incorporated
into sexual activity with another person in order to produce sexual
excitation.

arousal from either the use of nonliving objects or a highly specific
focus on non-genital body part(s), as manifested by fantasies, urges, or
behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant
of functioning.
C. The fetish objects are not limited to articles of clothing used in
cross-dressing (as in transvestic disorder) or devices specifically
designed for the purpose of tactile genital stimulation (e.g., vibrator).

Frotteuristic Disorder
• Frotteuristic disorder is the recurrent and intense sexual arousal
(manifested by urges, behaviors, or fantasies of at least 6 months’
duration) involving touching or rubbing against a nonconsenting person
(APA, 2013).
• Sexual excitement is derived from the actual touching or rubbing, not from
the coercive nature of the act. Almost without exception, the gender of the
frotteur is male.
• The individual usually chooses to commit the act in crowded places, such
as on buses or subways during rush hour. In this way, he can provide
rationalization for his behavior, should someone complain, and can more
easily escape arrest.
• The frotteur waits in a crowd until he identifies a victim, then he follows
her and allows the rush of the crowd to push him against her.

• He fantasizes a relationship with his victim while rubbing his genitals
against her thighs and buttocks or touching her genitalia or breasts
with his hands. He often escapes detection because of the victim’s
initial shock and denial that such an act has been committed in this
public place.

arousal from touching or rubbing against a nonconsenting person, as
manifested by fantasies, urges, or behaviors.
of functioning.

Pedophilic Disorder
• The essential feature of pedophilic disorder is sexual arousal from
prepubescent or early pubescent children equal to or greater than
that derived from physically mature persons.
• DSM-5 criteria specify that the behavior has lasted at least 6 months
and is manifested by fantasies or sexual urges on which the individual
has acted, or which cause significant distress or impairment in social,
occupational, or other important areas of functioning (APA, 2013).
• The age of the molester is at least 16 years, and he or she is at least 5
years older than the child. This category of paraphilic disorder is the
most common of sexual assaults.

• Most child molestations involve genital fondling or oral sex. Vaginal or
anal penetration of the child is most common in cases of incest.
• Sexual abuse of a child may include a wide range of behaviors,
including speaking to the child in a sexual manner, indecent exposure
and masturbation in the presence of the child, and inappropriate
touching or acts of penetration (oral, vaginal, and anal) (King, 2011).
• Onset usually occurs during adolescence, and the disorder often runs
a chronic course.

A. Over a period of at least 6 months, recurrent, intense sexually
arousing fantasies, sexual urges, or behaviors involving sexual
activity with a prepubescent child or children (generally age 13 years
or younger).
B. The individual has acted on these sexual urges, or the sexual urges
or fantasies cause marked distress or interpersonal difficulty.

Sexual Masochism Disorder
• The identifying feature of sexual masochism disorder is recurrent and
intense sexual arousal (manifested by urges, behaviors, or fantasies of at
least 6 months’ duration) from the act of being humiliated, beaten,
bound, or otherwise made to suffer (APA, 2013).
• These masochistic activities may be fantasized (e.g., being raped) and
may be performed alone (e.g., self-inflicted pain) or with a partner (e.g.,
being restrained, spanked, or beaten by the partner).
• Some masochistic activities have resulted in death, in particular those that
involve sexual arousal by oxygen deprivation.
• The disorder is usually chronic and can progress to the point at which the
individual cannot achieve sexual satisfaction without masochistic fantasies
or activities.

arousal from the act of being humiliated, beaten, bound, or
otherwise made to suffer, as manifested by fantasies, urges, or
behaviors.
of functioning.

Sexual Sadism Disorder
• The DSM-5 identifies the essential feature of sexual sadism disorder
as recurrent and intense sexual arousal (manifested by urges,
behaviors, or fantasies of at least 6 months’ duration) from the
physical or psychological suffering of another individual (APA,2013).
• The sadistic activities may be fantasized or acted on with a
consenting or nonconsenting partner.
• In all instances, sexual excitation occurs in response to the suffering of
the victim.
• Examples of sadistic acts include restraint, beating, burning, rape,
cutting, torture, and even killing.

• The course of the disorder is usually chronic, with the severity of the
sadistic acts often increasing over time. Activities with nonconsenting
partners are usually terminated by legal apprehension.

arousal from the physical or psychological suffering of another
person, as manifested by fantasies, urges, or behaviors.
of functioning.

Transvestic Disorder
• Transvestic disorder involves recurrent and intense sexual arousal (as
manifested by fantasies, urges, or behaviors of at least 6 months’
duration) from dressing in the clothes of the opposite gender.
• The individual is commonly a heterosexual man who keeps a
collection of women’s clothing that he intermittently uses to dress in
when alone. The sexual arousal may be produced by an
accompanying fantasy of the individual as a woman with female
genitalia, or merely by the view of himself fully clothed as a woman
without attention to the genitalia.
• The disorder causes marked distress to the individual, or interferes
with social, occupational, or other important areas of functioning.

arousal from cross-dressing, as manifested by fantasies, urges, or
behaviors.
of functioning.

Voyeuristic Disorder
• Voyeuristic disorder is identified by recurrent and intense sexual
arousal (manifested by urges, behaviors, or fantasies of at least at
least 6 months’ duration) involving the act of observing an
unsuspecting individual who is naked, in the process of disrobing, or
engaging in sexual activity (APA, 2013).
• Sexual excitement is achieved through the act of looking, and no
contact with the person is attempted. Masturbation usually
accompanies the “window peeping” but may occur later as the
individual fantasizes about the voyeuristic act.

• Onset of voyeuristic behavior commonly occurs during adolescence,
but the minimum age for a diagnosis of voyeuristic disorder is 18
years (APA, 2013).
• Many individuals who engage in this behavior enjoy satisfying sexual
relationships with an adult partner.
• Few apprehensions occur because most targets of voyeurism are
unaware that they are being observed.

A. Over a period of at least 6 months, recurrent and intense sexual arousal
from
observing an unsuspecting person who is naked, in the process of disrobing,
or
engaging in sexual activity, as manifested by fantasies, urges, or behaviors.
person, or the sexual urges or fantasies cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
C. The individual experiencing the arousal and/or acting on the urges is at
least 18 years of age.

Predisposing Factors to Paraphilic Disorders
• Biological Factors
• Various studies have implicated several organic factors in the etiology of
paraphilic disorder. Destruction of parts of the limbic system in animals has
been shown to cause hypersexual behavior (Becker & Johnson,2008).
• Temporal lobe diseases, such as psychomotor seizures or temporal lobe
tumors, have been implicated in some individuals with paraphilic disorder.
• Abnormal levels of androgens also may contribute to inappropriate sexual
arousal.
• The majority of studies have involved violent sex offenders, and the results
cannot accurately be generalized.

Psychoanalytic Theory
• The psychoanalytic approach defines an individual with paraphilic
disorder as one who has failed the normal developmental process
toward heterosexual adjustment (Sadock & Sadock, 2007).
• This occurs when the individual fails to resolve the Oedipal crisis and
either identifies with the parent of the opposite gender or selects an
inappropriate object for libido cathexis.

Behavioral Theory
• The behavioral model hypothesizes that whether or not an individual
engages in paraphilic behavior depends on the type of reinforcement
he or she receives following the behavior.
• The initial act may be committed for various reasons. Some examples
include recalling memories of experiences from an individual’s early
life (especially the first shared sexual experience) modeling
behavior of others who have carried out paraphilic acts, mimicking
sexual behavior depicted in the media, and recalling past trauma such
as one’s own molestation (Sadock & Sadock, 2007).

• Once the initial act has been committed, the individual with
paraphilic disorder consciously evaluates the behavior and decides
whether to repeat it.
• A fear of punishment or perceived harm or injury to the victim, or a
lack of pleasure derived from the experience, may extinguish the
behavior.
• However, when negative consequences do not occur, when the act
itself is highly pleasurable, or when the person with the paraphilic
disorder immediately escapes and thereby avoids seeing any negative
consequences experienced by the victim, the activity is more likely to
be repeated.

Transactional Model of Stress/Adaptation
• One model alone is probably not sufficient to explain the etiology of
paraphilic disorders.
• It is most likely that the integration of learning experiences,
sociocultural factors, and biological processes must occur to account
for these deviant sexual behaviors.
• A combination of biological, psychosocial, and cultural factors, along
with aspects of the learning paradigm previously described,
probably provides the most comprehensive etiological explanation
for paraphilic disorders to date.

Treatment Modalities for Paraphilic Disorders
• Biological Treatment
• Behavior Therapy
• Psychoanalytic Therapy

Biological Treatment
• Biological treatment of individuals with paraphilic disorders has focused
on blocking or decreasing the level of circulating androgens.
• The most extensively used of the antiandrogenic medications are the
progestin derivatives that block testosterone synthesis or block androgen
receptors.
• They do not influence the direction of sexual drive toward appropriate
adult partners.
• Instead they act to decrease libido, and thus break the individual’s pattern
of compulsive deviant sexual behavior (Becker & Johnson, 2008).
• They are not meant to be the sole source of treatment and work best when
given in conjunction with participation in individual or grou psychotherapy.

Psychoanalytic Therapy
• Psychoanalytic approaches have been tried in the treatment of
paraphilic disorders.
• In this type of therapy, the therapist helps the client to identify
unresolved conflicts and traumas from early childhood.
• The therapy focuses on helping the individual resolve these early
conflicts, thus relieving the anxiety that prevents him or her from
forming appropriate sexual relationships.
• In turn the individual has no further need for paraphilic fantasies.

Behavior Therapy
• Aversion techniques have been used to modify undesirable behavior.
• Aversion therapy methods in the treatment of paraphilic disorders involve
pairing noxious stimuli, such as electric shocks and bad odors, with the impulse,
which then diminishes.
• Behavioral therapy also includes skills training and cognitive restructuring in an
effort to change the individual’s maladaptive beliefs.
• Other behavioral approaches to decreasing inappropriate sexual arousal have
included covert sensitization and satiation.
• With covert sensitization, the individual combines inappropriate sexual fantasies
with aversive, anxiety-provoking scenes under the guidance of the therapist
(Becker & Johnson,2008).
• Satiation is a technique in which the post-orgasmic individual repeatedly
fantasizes deviant behaviors to the point of saturation with the deviant stimuli,
consequently making the fantasies and behavior unexciting.

Treatment Modalities for Sexual Dysfunctions
• Sexual Desire Disorders
• Hypoactive Sexual Desire Disorder
• Hypoactive sexual desire disorder has been treated in both men and women with
the administration of testosterone. The masculinizing side effects make this
approach unacceptable to women, and the evidence that it increases libido in
men is inconclusive.
• Becker and Stinson (2008) describe the most effective treatment as a
combination of cognitive therapy to deal with maladaptive beliefs; behavioral
treatment, such as exercises to enhance sexual pleasuring and communication;
and relationship therapy to deal with the individual’s use of sex as a method of
control.
• Low sexual desire is often the result of partner incompatibility. If this is the case,
the therapist may choose to shift from the sexual issue to helping a couple
identify and deal with their incompatibility.

Sexual Arousal Disorders
• Female Sexual Interest/Arousal Disorder
• The goal of treatment for female sexual interest/arousal disorder is to
reduce the anxiety associated with sexual activity.
• Masters and Johnson (1970) reported successful results using their
behaviorally oriented sensate focus exercises to treat this disorder.
• The objective is to reduce the goal-oriented demands of intercourse
on both partners, thus reducing performance pressures and anxiety
associated with possible failure.

• The couple is instructed to take turns caressing each other’s bodies.
• Initially, they are to avoid touching breasts and genitals, and to focus
on the sensations of being touched.
• The caressing progresses to include touching of the breasts and
genitals, to touching each other simultaneously, and eventually to
include intercourse.
• These non-goal-oriented exercises promote the sensual side of sexual
interaction in a nonpressured, nonevaluative way (Masters et al.,
1995).

Erectile Disorder
• Sensate focus has also been used effectively for erectile disorder in
men.
• Clinicians widely agree that even when significant organic factors
have been identified, psychological factors may also be present and
must be considered in treatment.
• Group therapy, hypnotherapy, and systematic desensitization have
also been used successfully in reducing the anxiety that may
contribute to erectile difficulties.
• Psychodynamic interventions may help alleviate intrapsychic conflicts
contributing to performance anxiety (Becker & Stinson, 2008).

• Various medications, including testosterone and yohimbine, have
been used to treat erectile disorder.
• Penile injections of papaverine or prostaglandin have been used to
produce an erection lasting from 1 to 4 hours.
• However, this treatment is unacceptable to many men because of
pain of the injection and side effects, such as priapism and fibrotic
nodules in the penis (Becker & Stinson, 2008).
• Use of phosphodi-esterase-5 (PDE5) inhibitors such as sildenafil
(Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Stendra).

• These newer impotence agents block the action of phosphodi-
esterase-5 (PDE5), an enzyme that breaks down cyclic guanosine
monophosphate (cGMP), a compound that is required to produce
an erection.
• This action only occurs, however, in the presence of nitric oxide (NO),
which is released during sexual arousal.
• PDE5 inhibitors do not result in sexual arousal. They work to achieve
penile erection in the presence of sexual arousal.

• Phentolamine has been used in combination with papaverine in an
injectable form that increases blood flow to the penis, resulting in an
erection.
• Apomorphine acts directly on the dopamine receptors in the brain.
• This mode of stimulating dopamine in the brain is thought to enhance
the sexual response.
• For erectile disorder refractory to other treatment methods, penile
prostheses may be implanted. Two basic types are currently available:
a bendable silicone implant and an inflatable device.

Orgasmic Disorders
• Because anxiety may contribute to the lack of orgasmic ability in
women, sensate focus is often advised to reduce anxiety, increase
awareness of physical sensations, and transfer communication skills
from the verbal to the nonverbal domain.
• Treatment for secondary anorgasmia (in which the client has had
orgasms in the past, but is now unable to achieve them) focuses on
the couple and their relationship.
• Therapy with both partners is essential to the success of this disorder.

Delayed Ejaculation
• Treatment for delayed ejaculation is very similar to that described for
the anorgasmic woman.
• A combination of sensate focus and masturbatory training has been
used with a high degree of success.
• Treatment for male orgasmic disorder almost always includes the
sexual partner.

Premature (Early) Ejaculation
• Sensate focus is used, with progression to genital stimulation.
• When the man reaches the point of imminent ejaculation, his sexual
partner is instructed to apply the “squeeze” technique: applying
pressure at the base of the glans penis, using the thumb and first two
fingers. Pressure is held for about 4 seconds and then released.
• This technique is continued until the man is no longer on the verge of
ejaculating.
• This technique is practiced during subsequent periods of sexual
stimulation.

Genito-Pelvic Pain/Penetration Disorder
• Systematic desensitization has been used successfully to decrease fears
and anxieties associated with painful intercourse.
• The second phase of treatment involves systematic desensitization. The
client is taught a series of tensing and relaxing exercises aimed at
relaxation of the pelvic musculature.
• Relaxation of the pelvic muscles is followed by a procedure involving the
systematic insertion of dilators of graduated sizes until the woman is able
to accept the penis into the vagina without discomfort.
• This physical therapy, combined with treatment of any identified
relationship problems, has been used with considerable success (Masters
et al., 1995)

Gender Dysphoria in Adolescents or Adults
• With this condition, an individual, despite having the anatomical
characteristics of a given gender, has the self-perception of being of
the opposite gender.
• Individuals with this disorder do not feel comfortable wearing the
clothes of their assigned gender and often engage in cross-dressing.
• They may find their own genitals repugnant and may repeatedly
submit requests to the health-care system for hormonal and surgical
gender reassignment.
• Depression and anxiety are common and are often attributed by
the individual to his or her inability to live in the desired gender role.

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6
months’ duration, as manifested by at least two of the following:
1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary
sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
2. A 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 (or in young adolescents, a desire to prevent the
development of the anticipated secondary sex characteristics).
3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned
gender).
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative
gender different from one’s assigned gender).
B. The condition is associated with clinically significant distress or impairment in social, occupational, or
other important areas of functioning.

Treatment Issues
• In most cases, the individual must undergo extensive psychological testing
and counseling, as well as live in the role of the desired gender for up to 2
years before surgery.
• Hormonal treatment is initiated during this period. Male clients receive
estrogen, which results in a redistribution of body fat in a more “feminine”
pattern, enlargement of the breasts, a softening of the skin, and reduction
in body hair.
• Women receive testosterone, which also causes a redistribution of body
fat, growth of facial and body hair, enlargement of the clitoris, and
deepening of the voice (Becker & Johnson, 2008).
• Amenorrhea occurs within a few months.

• Surgical treatment for male-to-female transgender reassignment
involves removal of the penis and testes and creation of an artificial
vagina.
• Care is taken to preserve sensory nerves in the area so that the
individual may continue to experience sexual stimulation.
• Surgical treatment for female-to-male transgender reassignment is
more complex. A mastectomy and sometimes a hysterectomy are
performed. A penis and scrotum are constructed from tissues in the
genital and abdominal area, and the vaginal orifice is closed. A penile
implant is used to attain erection.

• Both men and women continue to receive maintenance hormone
therapy following surgery.
• Satisfaction with the results is highest among clients who are
emotionally healthy, have adequate social support, and attain
reasonable cosmetic results.

• Nursing care of the post-gender-reassignment surgical client is similar
to that of most other postsurgical clients.
• Particular attention is given to maintaining comfort, preventing
infection, preserving integrity of the surgical site, maintaining
elimination, and meeting nutritional needs.
• Psychosocial needs may have to do with body image, fears and
insecurities about relating to others, and being accepted in the new
gender role.
• Meeting these needs can begin with nursing in a nonthreatening,
nonjudgmental healing atmosphere.

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