Human sexuality is influenced by genetic, biological, psychosocial, and cultural factors. It involves behaviors, relationships, gender identity, sexual orientation, and other expressions that begin developing in childhood. Sexual issues can include paraphilias (abnormal sexual interests), dysfunctions (problems with sexual arousal, desire, or orgasm), and disorders of gender identity or sexual pain. Treatment may involve psychotherapy, behavioral therapy, medication, or surgery depending on the specific issue.

3. Human sexuality in perspective An optimal survey of sexual deviations or sexual disorders must take into account the broader expanse of human sexuality… What is human sexuality?

4. Sexuality The sum of a person’s sexual behaviors and tendencies, and the strength of such tendencies (Stedman’s Medical Dictionary)

5. Factors affecting sexuality Genotype – the genes of an individual provide the biologic basis of sexuality Socio-cultural heritage – influence and modify the effects of genetic endowment Physical environment – also modify the effects of the genetic make-up and the socio-cultural heritage

6. Expressions of sexuality Appearance Attitudes Behaviors Relationships Influenced by ongoing biophysical and psychosocial factors, sexuality starts to take shape during early childhood and is reshaped throughout life

7. Components of sexual identity Biosexual identity – from genetic and hormonal influences (XX, XY, etc) Gender role – outward expression of gender – the behaviors, feelings, and attitudes appropriate for either a male or a female Gender identity – a person’s private experience of gender – the sense of oneself as being male, female, or ambivalent

8. Components of sexual identity 2 Sexual orientation or preference – refers to a person’s about his or her sexual attraction and erotic potential Heterosexuality Homosexuality Bisexuality

9. Sexual orientation Heterosexuality - sexual arousal from or sexual activity with people of the opposite gender Homosexuality – sexual arousal from or activity with people of the opposite gender Bisexuality - sexual arousal from or sexual activity with both males and females

11. “ Abnormal” sexual behavior Definition depends largely on cultural and historical context Accepted norms of sexual behaviors and attitudes vary greatly within and among different cultures In the past sexual intercourse for procreation was considered as the only “normal” sexual behavior

12. Other opinions… Sexual behavior is abnormal if it causes personal distress Sexuality is a continuum from adaptive to maladaptive: normal sexuality is adaptive; abnormal sexuality is maladaptive – the behavior is maladaptive if it impairs individual goals and disrupts social group functioning

13. Stages of sexual development Infancy to age 5 Ages 5 to 10 Ages 10 to 14 Ages 14 and older Adulthood

15. Taking the stigma off homosexuality and masturbation Homosexuality is now widely considered as a normal variant of sexuality ( Until the 70’s psychiatrists officially described homosexuality as abnormal ) Masturbation was once widely seen as a perversion and a potential cause of mental disorders

16. Sexual disorders Sexual disorders described in DSM-IV-TR include: Paraphilias Sexual dysfunctions Sexual pain disorders Gender identity disorder

17. Paraphilias Complex psychosexual disorders marked by sexual urges, fantasies, or behaviors that center on: inanimate objects such as clothing suffering or humiliation children or other non-consenting persons All paraphilias involve an attraction to a non-sanctioned source of sexual satisfaction

18. Paraphilias 2 Source of satisfaction may be a behavior as with exhibitionism or sadism , or a forbidden object of attraction as with pedophilia or fetishism Paraphilias commonly involve sexual arousal and orgasm, usually achieved through masturbation and fantasy Usually a paraphilia is chronic and lifelong The paraphiliac urge, fantasy, or behavior is always present

19. streaking

20. Paraphilias 3 Rarely diagnosed in clinical settings because people with paraphilias are secretive about them In paraphilia clinics, the most common disorders seen include pedophilia, voyeurism, and exhibitionism. Sadomasochism is much less common

21. Paraphilias 4 Majority of paraphiliacs are males except for masochism where females outnumber males by 20 to 1 Some paraphilias are crimes in many jurisdictions (those that involve or harm another person) are considered criminal acts: pedophilia, exhibitionism, voyeurism, frotteurism, and sexual sadism

22. Paraphilias 5 Exhibitionists, pedophiles, and voyeurs make up the majority of apprehended sex offenders Sex offenses against children as in pedophilia, constitute a significant portion of reported criminal sex acts

23. Exhibitionism One of the most common paraphilias Marked by sexual fantasies, urges, or behaviors involving surprise exposure of the male genitals to strangers , primarily female passersby (female exhibitionists are rare) in public places It is meant to be shocking otherwise it loses it power to sexually arouse the paraphiliac

24. Exhibitionism 2 The most prominent sexual offense leading to arrest Usually begins during adolescence and continues into adulthood It may become lifelong if untreated It commonly becomes less severe by age 40

25. Fetishism Characterized by sexual fantasies, urges, or behaviors that involve the use of a fetish – a non-human object or a non-sexual part of the body to produce or enhance sexual arousal Fetishism may involve a partner. Sometimes focusing on certain parts of the body like the feet, hair, or ears can become a fetish Some people achieve sexual gratification only when using a fetish

26. Forms of fetishism Involves a partner and associates sexual activity with some object as women’s panties or body part. The foot is the most commonly used body in fetishism. In the extreme form of fetishism, a non-living object completely replaces a human partner : underwear, boots, velvet, silk, etc. Fondling the object when alone results in orgasm.

27. Transvestic fetishism A heterosexual male partially (usually hidden under male clothing) or fully dresses in female clothes ( cross-dressing ) to produce or enhance sexual arousal Transvestites believe they have both male and female personalities . Cross-dressing allows them to display their feminine side. Commonly involves masturbation and metal images of men attracted to the patient as a “woman”

28. Truth about transvestites Myth – transvestites are homosexuals Truth – 90% of transvestites are heterosexual Myth - transvestites act like women even when wearing men’s clothes Truth – for fear of being discovered, they try to act as traditionally masculine as possible

29. Truth about transvestites 2 Myth – transvestites are effeminate Truth – transvestites are no more effeminate than other males Myth – transvestites want to become women Truth – few transvestites wish to change sexes

30. Truth about transvestites 3 Myth - Transvestites cross-dress because they were dressed as girls when they were children Truth – Although many transvestites first experienced cross-dressing in childhood, in many cases they initiated these experiences themselves to play out fantasies about gender role

31. Pedophilia Marked by sexual fantasies, urges, or activity involving a child, usually age 13 or younger In adolescent pedophilia the child is 5 years younger than the adolescent The

32. Pedophile activity During the act the pedophile may – Undress the child Encourage the child to watch him masturbate Touch or fondle the child’s genitals Forcefully perform sexual acts on the child Pre-pubertal children are the most common targets

33. Causes of paraphilias Behavioral theory – child who was the victim or observer of inappropriate sexual behaviors learns to imitate such behavior and gets reinforcement for it Biological theory – hormonal, behavioral, and CNS interaction – especially the role of aggression and male sex hormones

34. Factors that contribute to paraphilias Dysfunctional families marked by isolation, sexual, emotional, and physical abuse Psychoactive substance use Concurrent mental or personality disorders Closed head injury CNS tumors

35. Factors… History of emotional or sexual trauma Lack of knowledge about sex Neuroendocrine disorders Psychosocial stressors

36. Signs and symptoms Anxiety Depression Hobby or occupation change that makes the paraphilia more accessible Disturbance in body image Guilt or shame Ineffective coping Multiple paraphilias at the same time

37. Signs and symptoms 2 Purchase of books, videos, or magazines related to the paraphilia or frequent visits to paraphilia-related websites Recurrent fantasies involving a paraphilia Sexual dysfunction Social isolation Troubled sexual or social relationships

38. Diagnosis Penile pletysmography – measurement of patient’s sexual arousal in response to visual imagery DSM-IV-TR criteria

39. Treatment Paraphiliacs seldom seek treatment because of their guilt, shame, and fear of social ostracism and legal problems Depending on the specific paraphilia, treatment may involve a combination of psychotherapy, cognitive therapy, behavioral therapy, pharmacotherapy, and surgery

40. Paraphilia-related disorders Compulsive masturbation Protracted promiscuity – cannot maintain a monogamous relationship Pornography dependency Telephone sex Severe sexual desire Repetitive use of sexual toys

41. Rare paraphilias Coprophilia - feces Emetophilia - vomit Hybristophilia – crimes Klismaphilia - enemas Necrophilia - corpses Plushophilia – stuffed toys Uroglagnia - urine Zoophilia - animals

42. Sexual dysfunctions Characterized by pain during sex or by a disturbance in one of the phases of the sexual response cycle May cause marked distress and interpersonal problems Can impair intimate relationships by reducing the enjoyment of normal sex or preventing the normal changes of the sexual response cycle

43. Sexual dysfunctions Sexual arousal disorders Sexual desire disorders Orgasmic disorders Sexual dysfunction caused by a medical condition Sexual pain disorders Commonly linked to psychological factors, medical conditions, substance use, etc.

44. Female sexual arousal disorder Inability to achieve or maintain an adequate lubrication-swelling response One of the most severe sexual dysfunctions in women Usually reports limited or absent sexual desire and little or no pleasure from sexual stimulation

45. Female orgasmic disorder Defined as the inability to achieve an orgasm The most common sexual dysfunction in women Unlike a woman with a sexual arousal disorder, one with orgasmic disorder may desire sexual activity and become aroused, but feels inhibited as she approaches orgasm

46. Causes of sexual arousal and orgasmic disorders Depression Drug use – CNS depressants, antidepressants, hormonal contraceptives, alcohol, or street drugs Discordant relationships Diseases Fatigue Gynecologic factors

47. Causes of sexual arousal and orgasmic disorders 2 Inadequate or ineffective sexual stimulation Lifestyle disruptions Psychological factors – stress, anxiety, anger, hostility, boredom with sex, guilt, depression, etc Pregnancy Religious or cultural taboos that reinforce guilt about sex

48. Manifestations Female arousal disorder – Decreased sexual desire Individual or family stress or fatigue Poor self esteem or body image Persistent or recurrent, partial or complete failure to attain or maintain the lubrication-swelling response Marked distress or interpersonal difficulty

49. Manifestations Female orgasmic disorder – Persistent or recurrent delay in or the absence of orgasm after a normal sexual excitement phase during sexual activity deemed to be adequate Patient suffers marked distress

50. Treatment of sexual arousal disorder Help patient relax, become aware of feelings regarding sex, eliminate guilt and fear of rejection Reassurance Psychotherapy / behavioral therapy Sensate focus exercises -

51. Treatment of orgasmic disorder Decrease or eliminate involuntary inhibition of the orgasmic reflex Treatment may include experiential therapy, psychoanalysis, or behavior modification Individual therapy, marital or couples therapy, or sex therapy may be indicated Medications to decrease symptoms Treatment of underlying physical disorder

52. Premature ejaculation Male’s inability to control the ejaculatory reflex during sexual activity Ejaculation occurs before or immediately after penetration or before the wishes of both partners Affects men of all ages Doesn’t affect the ability to have an erection Can seriously disrupt intimate relationships

53. Causes of premature ejaculation Psychological factors – stress, performance anxiety, or limited sexual experiences Ambivalence or unconscious hatred towards women Negative sexual relationships – unconsciously denying the partner sexual fulfillment Guilt feelings about sex

54. Signs and symptoms Cannot prolong foreplay Ejaculates as soon as vagina is entered Partner seeks psychiatric treatment… Anxiety, depression, disturbance of body image Frustration, feelings of being unattractive Ineffective coping Dyspareunia, Poor self-concept, social isolation

55. Sexual pain disorders: Dyspareunia Unexplained genital pain occurs before, during, or after intercourse May be mild or severe enough to restrict the enjoyment of sex Causes: GU infections, allergy to condoms, diaphragms; tumors, PID, endometriosis, scars, insufficient lubrication, intact hymen, local trauma, etc

56. Dyspareunia, cont. Treatment : lubricants, treatment of infections, hymenal scar removal, gentle stretching of scars in vaginal opening, change in coital position Psychotherapy may be included if the condition has a psychological cause

57. Vaginismus Involuntary spasmodic muscle contractions occur at the entrance to the vagina when the male tries to insert his penis Pain occurs if intercourse is attempted despite these contractions, making intercourse extremely painful or impossible Possibly a learned response secondary to previous experience of dyspareunia

58. Gender identity disorder Marked by discomfort with one’s apparent or assigned gender and a strong, persistent, identification with the opposite sex 3 components of gender identity: self-concept, perception of an ideal partner, and external presentation of gender through behavior, dress, or mannerisms

59. Causes of gender identity disorder Chromosomal anomalies Hormonal imbalances Pathologic defects in early parent-child bonding (dressing up a child as a member of the opposite sex) Paraphilias Feelings of sexual inadequacy Generalized anxiety disorder Personality disorders

60. Treatment, gender identity disorder Individual and couple therapy Psychiatric management Hospitalization Group or individual psychotherapy For a child, individual and family therapy

61. Sadism A person achieves sexual gratification by inflicting pain, cruelty, or emotional abuse on others The sexual sadist may verbally humiliate his partner and abuse her physically through torture, whipping, cutting, binding, beating, burning, stabbing, or rape