The DSM-IV defines 3 types of sexual disorders:

1) Gender Identity Disorder: A person feels psychologically dissatisfaction with their biological sex.

2) Sexual Dysfunction: A person finds it tough to function adequately during sex encounters.

3) Paraphilias: (para: abnormal; philia: strong attraction) A person’s sexual arousal occurs primarily to inappropriate objects or individuals.

What is normal sexual behaviour? Or abnormal sexual behaviour?

- Of course, it depends a number of factors. Three important determining factors are; 1) the current culture’s view of sexuality (i.e., how tolerant or intolerant), 2) if the behaviour is associated with substantial impairment in functioning, and 3) how the data about sexual behaviour is gathered.

- Billy, Tanfer, Grady and Keplinger (1993) interviewed 3321 men aged 20-39 about their sexual practices. The found the following:

- 95.4% had had vaginal intercourse;

- 78.8% had received oral sex; 74.6 had performed oral sex;

- 20.1% had anal sex;

- 28.2% had 1-3 sexual partners;

- 23.3% had 20 or more sexual partners;

- 70% had 1 sexual partner for the last year;

- 9% had more than 4 partners in the last year;

- 2.3% had had homosexual sex;

- 1.1% engaged exclusively in homosexual sex.

- These data have been replicated, for the most part, in studies of over 20000 men and women in Britain and France.

- Other interesting studies: 50% of men and 36% of women from 75-79 are sexually active. Why the 14% difference? (men die earlier).

Some interesting gender difference:

- 81% of men masturbate; only 45% of women masturbate. (This is also true in other primates, which suggests it is just easier for males);

- Men have a more permissive attitude toward premarital sex; however the gap between males and females has shrunk considerably in the last 10 years;

- Men are slightly younger at age of first intercourse;

- Men define a good sexual relationship in terms of just thatà sex, or arousal aspects; women define a good sexual relationship in terms demonstrations of love and intimacy during sex.

- No gender differences in terms of:

- Attitudes toward homosexuality (generally accepted);

- Experience of sexual satisfaction (important to both men and women);

- Attitudes toward masturbation (generally accepted).

- Concordance rate for homosexuality is higher for monozygotic twins (about 50%) than for dizygotic twins (about 20%). This suggests a genetic predisposition.

- Others suggest that sexual orientation is associated with prenatal exposure to certain sex hormones.

- The primary conclusion based on these reports by the media is that sexual orientation has a biological cause. Is this good or bad?

- Well it depends on who you talk to. Some are very happy since the biological predisposition makes it difficult for others to assume that homosexuals are morally deprave or deviant. Others, however, are concerned about the implications of such findings, i.e., the abnormality may be able to be fixed on day through genetic screening.

- Most models of sexual orientation however contend that there are most likely many different pathways to the development of homosexuality or heterosexuality. It is unlikely that one factor (either biological or psychological) will be able to predict sexual orientation. Like everything else we’ve talked about, while the biology in regards to sexual orientation will more than likely be discovered some day, the environment and experience will undoubtedly influence how these biological patterns are expressed.

- Remember: 50% of the identical twins mentioned about did not have the same sexual orientation although the have the same genetics.

- Also males growing up with an older brother are more likely to be homosexual. In fact, the more older brothers the greater the probability of being homosexual. This suggests a strong environmental influence.

- It is more than just your anatomy, or your reactions to family or the expectations of society that makes you think you are a male or female.

- Your maleness or femaleness is a deep-seated personal attribute called gender identity.

- Gender identity disorder (or transsexualism) occurs when physical gender is not consistent with a person’s sense of identity.

- The disorder is relatively rare, about 2-4 in every 100000, with males being twice as likely to be trapped in the wrong body.

- It is not transvestic fetishism, a paraphilic disorder, where persons (often males) are sexually aroused by wearing typically female clothing. On occasion the male may prefer the female role, but the primary goal of cross-dressing is sexual fulfillment.

- With gender identity disorder the primary goal is not sexual, but rather the desire to live one’s life as a member of the opposite sex.

- Similarly, gender identity disorder is not hermaphroditism (persons born with ambiguous genitalia, often associated with documented hormonal or other physical abnormalities). Usually, and depending on the genitalia development, hermaphrodites are assigned to a particular sex at birth and given surgery and or hormone therapy to enhance their sexual anatomy. Persons with gender identity disorder do not have physical abnormalities.

- Gender identity disorder must also be differentiated from homosexual arousal patterns. Homosexuals, even if they display effeminate (for male) or masculine (for female) patterns of behaviour do not feel trapped in the wrong body. In fact, in the DSM-IV sexual arousal patterns are of no concern for gender identity disorder, i.e., they do not matter. For example, consider a female with a masculine gender identity. She is attracted to men. She undergoes surgery to become a man, but he is still attracted to men. Thus, the heterosexual woman before surgery is now a homosexual male.

Causes:

- We’re not sure!

- However, it is likely due to a biological predisposition. Some research has discovered slightly higher levels of testosterone or estrogen at certain critical periods in development that may masculinize a female or feminize a male fetus.

- Such variations could result naturally, or because of an external teratogen (i.e., a drug or medication taken during pregnancy).

- Early research suggests subtle brain variations in males with gender identity disorder. Their brains are more feminine. Again these findings are correlational thus we don’t know if this is a cause or an effect.

- The most common treatment is sex reassignment surgery.

- To qualify for this treatment individuals must live in the opposite-sex role for between 18-24 months. They must also be stable psychologically, financially, and socially. Why is this important?

- Approximately 75% of cases report success, with female-to-male fairing slightly better than male-to-female cases.

- In a few cases psychosocial therapy has been successful. Basically this technique teaches the individual appropriate gender type behaviour, i.e., teach a male to be a male.

- The DSM-IV categories sex dysfunctions in terms of the sexual response cycle: desireà arousalà orgasm.

- Males and females experience similar or parallel forms of most sexual disorders, with the exception of two specific disorders, premature ejaculation in males, and vaginismus in women.

- Sexual dysfunctions can be acquired (and last only for a short time) or may be lifelong.

- Similarly sexual dysfunctions can be generalized (occurring every time sex is attempted) or situational (occurring with only some partners or only at certain times).

- Sexual dysfunctions are further classified as either 1) due to psychological factors or b) due to psychological factors combined with a general medical condition.

- Individuals have no interest in sexual activity.

- These disorders are difficult to assess and much clinical judgement is required.

- Some guidelines may include:

- Less than 2 sexual encounters a month, if the person is married, or

- By the lack of thinking or fantasizing about sex.

- These guidelines are by no means hard and fast:

- Some individuals have sex more than twice a month in order to appease their partner (i.e., live up to their end of the marriage), but feel no desire.

- About 50% of all sexual dysfunction cases are of the hypoactive sexual desire type.

- Women are more likely than men to have hypoactive sexual desire; men more often present with erectile problems.

- Most patients with hypoactive sexual desire;

- Rarely fantasize about sex;

- 35% of women and 52% of men never masturbate, the remainder masturbate less than once a month;

- These individuals rarely (less than once a month) initiate or attempt intercourse.

- In these individuals even the thought of sex or a brief casual touch may evoke fear, disgust or even panic!

- About 25% may actually have panic disorder.

- These disorders are commonly referred to as ‘male erectile disorder’ and ‘female sexual arousal disorder’.

- Many persons experience the desire for sex (i.e., great sexual fantasies) but their problem is with becoming physically aroused.

- In males, the problem is one of achieving or maintaining and erection.

- In females, the problem is the lack of adequate lubrication.

- Generally males feel much more impaired by this problem. Why?

- It is rare for a man to be completely unable to achieve an erection. In most cases men achieve full erections during masturbation, but only partial ones during coitus (not enough rigidity to achieve penetration).

- 40% of men report occasional erectile and ejaculatory difficulties.

- 63% of women report occasional problems with arousal or orgasm.

Note: the overwhelming majority of these individuals still expressed overall sexual satisfaction even though they had the occasional arousal problem.

- Erectile dysfunction is the most common problem for which men seek help.

- It is estimated that 40% of men in their 40s and 70% of men in their 70s will experience such problems.

- It is more difficult to estimate in women since many women still do not perceive absence of arousal to be a problem (however this is changing).

- Given this information estimates range from 15-48%.

- This is much more commonly seen in women, but it does occur in men.

- This is the most common complaint for women who seek counseling for a sexual problem.

- It is estimated that only 50% of women experience regular orgasms during sexual intercourse, and 10% never reaching orgasm.

- In contrast more than 90% of men regularly experience orgasm.

- Some men may have ‘retarded or delayed ejaculation’;

- Rarely, men suffer from ‘retrograde ejaculation’ (i.e., the sperm end up in the bladder).

- This is much more common than inhibited orgasm in men.

- Ejaculation occurs fast! Usually well before the man and his partner want it to.

- Estimates suggest that 35% of men have this problem. And 60% of the population seeking treatment present with premature ejaculation. Have you seen the movie American Pie?

- In terms of time, ejaculation occurs no longer than 1 or 2 minutes after insertion. In persons without this complaint insertion typically lasts 7-10 minutes.

- It appears the perception of lack of control over ejaculation is a primary psychological factor.

- This generally occurs in younger, less experienced males and therefore tends to decline with age.

- Behavioural treatments are also very effective, ‘i.e., the squeeze technique’.

- For some people who have desire, can perform, and can achieve orgasms sex is associated with pain, (i.e., severe headache following ejaculation).

- The diagnosis is made only when a medical reason cannot be found.

- The disordered is rarely seen in clinics, but it is thought to be present in about 1% of the male population and 10% of the female population [i.e., vaginismus: involuntary spasm of pelvic muscles in the outer third of the vagina during attempted penetration, (i.e., coitus, tampon, gynecological exam)].

- Vaginismus is much more common in cultures with very conservative views on sexuality.

- Many physical and medical conditions can effect sexual behaviour.

- Disorders like diabetes, kidney disease and vascular disease (arterial insufficiency, venous leakage) reduce sensitivity of the genital area and thus frequently cause erectile dysfunction in males and poor lubrication in females.

- Chronic illness, i.e., heart disease, is another common factor. Many folks believe that having sex may kill themà thus they are unable to become sexually aroused.

- Prescription and nonprescription drugs medication: many drugs interfere with sexual arousal.

- Antihypertensive drugs;

- Antidepressants, i.e., prozac; 75% of individuals taking prozac have some sexual dysfunction;

- Alcohol;

- Stimulants.

- Many believe that anxiety (i.e., performance anxiety) is the principal cause of many sexual dysfunctions. However, the picture is not that clear cut.

- Lab findings suggest that for:

1) Normal functioning men:

a) Performance anxiety appears to increase arousal;

b) Distraction appears to decrease arousal;

c) Report arousal more accurately and significantly more often than men with sexual dysfunction;

d) Experience positive affect when talking about sexual subjects.

2) Men with Sexual Dysfunctions:

a) Performance anxiety decreases sexual arousal;

b) Distraction appears to have little effect on arousal; This is strange, any ideas?;

c) Underreport arousal levels (both actual and when compared to normal men);

d) Experience negative affect when confronted with sexual subjects.

- Thus, it appears that performance anxiety may consist of different components:

1) arousal; 2) cognitive aspects; 3) emotive responsiveness;

- Effective treatment would have to address all of these aspects!

- Not surprising the negative emotive component we discussed above may have come about from an early threatening learning experience associated with sexuality (i.e., getting caught masturbating; being raped).  These negative or fear responses associated with sexuality are sometimes referred to as erotophobia!

- Many anorgasmic women display greater guilt and shame over masturbation than their orgasmic counterparts. Anorgasmic women are also more likely to endorse myths about sexuality, and less likely to tell partners what will increase their sexual pleasure (i.e., direct clitoral stimulation). Thus, the problem is more likely to continue.   These attributes were likely developed from early experience, and often reflect cultural beliefs about sexuality.

- Wonder drugs (i.e., Viagra), that increases blood flow to the genitals in both men and women.

- Surgical techniques (i.e., penile implants);

- Vacuum device therapy;

Psychosocial:

- A simple, yet extremely effective treatment in most who experience sexual dysfunction is EDUCATION!;

-i.e., learning to relax.

For erectile dysfunction and orgasmic disorder:

- The goal is to try and eliminate the psychologically based aspects of performance anxiety.  To do this the following procedure is implemented:

- 1) Basic information about sexual functioning, myths, and increasing communication between partners; 

- 2) Sensate focus and nondemand pleasuring (nongenital pleasuring) 30-60 min;

- 3) Move to genital stimulation, but no intercourse;  Most men need clear instruction that erection is not the goal!

-4) Now the couple can have intercourse.  But not just any intercourse, it is divided into parts:

- Perhaps partial insertion with continued genital and nongenital stimulation;

- After a certain period of time full insertion can take place.

- Success with this technique is very good:

- About 60% for erectile dysfunction; and

- 70% for orgasmic disorder.

- With variations this learning technique has also shown positive results for:

- Vaginismus (about 80%); and

- 100% for Premature ejaculation (i.e., squeeze technique).

- Most adults point their sexual interest toward other physically mature adults (or late adolescents) who can freely give or withhold their consent.

- Some adults however have sexual interest and fantasies toward:

A) nonhuman objects like underwear, shoes, leather or a vacuum cleaner;

B) humiliation or experience of pain in either themselves or their partner;

C) children or other persons who do not give their consent.

- Diagnosis requires that the paraphilic desires be:

- Powerful and recurrent over a period of at least 3 months.

- The individual must have acted on the desires or be distressed by them (thus you can make the diagnosis solely on fantasiesà if they are distressing).

- Do not think that the all paraphilic individuals can only achieve sexual pleasure from their paraphilia. Many can function sexually without their preferred stimuli (many cases of pedophilia involve married men whose wives suspected nothing). However, some cannot become sexually aroused without their paraphilic desire. Thus, think of paraphilia as a continuum both in term of desire and severity (i.e., some paraphilic behaviours do not harm anyone (transvestic fetishism), while others can be devastating (pedophilia)).

- Prevalence is difficult to assess. While paraphilias are not thought to be widely prevalent, some types like transvestic fetishism appear common.

- Similarly, if you’ve ever been to a large city you may have been the victim of frotteurism.

- Paraphilia is much more common in men than women.

- An individual is sexually attracted to nonliving objects.

- Generally fetishism is associated with 2 classes of objects:

1) an inanimate object;

2) a source of specific tactile stimulation (i.e., rubber);

- A third, an older classification is:

3) partilism: a fetish for a specific part of the body (foot, hair, buttocks): Partilism is often too difficult to distinguish from normal patterns of arousal, and thus is no longer consider a fetish.

- Voyeurism is the practice of observing an unsuspecting individual naked or in the process of undressing and becoming aroused.

- Exhibitionism is achieving sexual arousal and gratification by exposing one’s genitals to unsuspecting strangers.

- Sexual gratification and arousal is associated with the act of dressing in garments usually reserved for the opposite sex (cross-dressing).

- Often men who engage in this fetish hold very ‘macho’ jobs (i.e., police officer) or associate with ‘macho’ institutions (paramilitary).

- About 60% of these individuals are married and often the wives of these individuals are very supportive and accepting of this behaviour.

- Sadism is associated with inflicting pain or humiliation;

- Masochism is associated with suffering pain or humiliation.

- Common scenarios include wearing a collar and leash, being tied or handcuffed to something (often a bed), whips, shiny black clothing, etc.)

- It is not uncommon for the violence to get out of hand and serious injury or death resulting (i.e., accidental hanging; Note: this should be distinguished from a closely related condition known as hypoxiphiliaà self-strangulation to reduce oxygen to the brain and enhance orgasm).

- However, most sadistic and masochistic behaviours are quite mild and harmless, but the potential for them to escalate (i.e., alcohol or other drugs) is ever present.

- Most rapes are not classified as paraphilia since they are better characterized by assault by an individual whose sexual arousal patterns are not typically paraphilic.

- I.e., unplanned assaults occurring during robberies, planned rape for vindication.

- However, certain rapists do in fact fit the definition of paraphilia and could be described as sadists.

- i.e., they derive pleasure from themes involving rape.

- Pedophilia: sexual attraction to children or very young adolescents. If the children are the person’s relatives then it is called incest.

- Individuals may be attracted to boys, girls or both.

- Generally victims of pedophilia are young kids, while victims of incest tend to be young girls who are beginning to mature physically.

- Incestuous males are, in general, more aroused by adult women, while pedophiles are more aroused by children.

- Some child molesters are both pedophilic and sadistic. They sometimes kill their victims. Thankfully, most child molesters are not physically violent. In fact, most molesters rationalize their behaviour as useful and loving, teaching the child about sexuality.

- The do not consider the psychological damage they are inflicting.

- Paraphilias often occur with other sexual or social (i.e., incomplete sexual relationships with other adults) problems;

- However, most individuals with these other problems do not develop paraphilia.

- Early experience may be a crucial factor (learning);

- I.e., rewarding of early sexual fantasies; (don’t forget this is often repeated);

- Also males tend to masturbate more than females, thus one would expect much more paraphiliaà and that is what we see.

- Most paraphilics tend to have a very strong sex drive. It is not uncommon for them to masturbate 3-4 (or more) times a day.

- Activity this consuming may be related to an obsessional process (OCD?).

- Along this line some researchers are interested in a biologically weak inhibitory control mechanism (i.e., the GABA system).

- Psychosocial Treatments:

- Most treatments are aimed at changing the associations and context from one of arousal to one that is neutral.

- The most common method is covert sensitization:

- Some components of covert sensitization include:

- Orgasmic reconditioning;

- Relapse prevention.

- This method appears to be very effective with success rates of 70 to 100% depending on the paraphilia. Note: these stats are based on relatively small numbers of clinical cases.

- Biological and Drug Treatments:

- Anti-androgen drugs are popular, i.e., cyproterone acetate, medroxyprogesterone;

- These drugs chemical castrate males, i.e., they reduce levels of testosterone.

- Surgical removal of the testicles.