Sexual Disorders and Gender Identity Disorder

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Chapter 13
Slides Handouts by Karen Clay Rhines, Ph.D.
Seton Hall University

• Sexual Disorders and Gender Identity Disorder

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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
  
• DSM-IV-TR 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

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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

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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

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Sexual Dysfunctions

• Some people struggle with sexual dysfunction
  their whole lives (labeled lifelong type in
  DSM-IV-TR)
  
• 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)

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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

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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-IV-TR refers to deficient sexual
  interest/activity but provides no definition of
  deficient
  
• In reality, this criterion is difficult to define

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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

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Disorders of Desire

• A persons 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

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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

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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

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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

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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)

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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

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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
• According to surveys, half of all adult men have
  erectile difficulty during intercourse at least
  some of the time

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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 is more common in single
  women than in married or cohabiting women

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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

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Disorders of Orgasm

• Female orgasmic disorder
• Biological causes
• A variety of physiological conditions can affect
  a womans 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
  
• Postmenopausal changes may also be responsible

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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

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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

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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
  womans intimate relationships (such as emotional
  intimacy) to orgasmic behavior

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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

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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

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Disorders of Sexual Pain

• Vaginismus
• Most clinicians agree with the cognitive-behaviora
  l 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

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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

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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

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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

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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

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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

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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 and general communication
  skills
  
• Changing destructive lifestyles and marital
  interactions
  
• Addressing physical and medical factors

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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

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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

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What Techniques Are Applied to Particular
Dysfunctions?

• Erectile disorder
• Treatments for ED focus on reducing a mans
  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

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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

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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

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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

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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

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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

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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 long-term sex partner

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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
  

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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

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Paraphilias

• According to the DSM-IV-TR, 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

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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 been proved
  clearly effective
  
• Recent work has focused on biological
  interventions

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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
• Womens underwear, shoes, and boots are
  especially common

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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

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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

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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

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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

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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 and is most common
  in males
  
• Treatment generally includes aversion therapy and
  masturbatory satiation
  
• May be combined with orgasmic reorientation,
  social skills training, or psychodynamic therapy

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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

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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

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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

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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
  
• Evidence suggests that two-thirds of victims are
  female

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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

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Pedophilia

• Most people with pedophilia are imprisoned or
  forced into treatment
  
• Treatments include aversion therapy, masturbatory
  satiation, and orgasmic reorientation
  
• Cognitive-behavioral treatment involves
  relapse-prevention training, modeled after
  programs used for substance dependence

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Sexual Masochism

• Characterized by fantasies, urges, or behaviors
  involving the act or the 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

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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

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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

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Sexual Sadism

• Biological studies have found possible
  abnormalities in the endocrine system
  
• The primary treatment for this disorder is
  aversion therapy

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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

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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

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Gender Identity Disorder

• Men with gender identity disorder outnumber women
  2 to 1
  
• People with gender identity disorder often
  experience anxiety or depression and may have
  thoughts of suicide

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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

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Gender Identity Disorder

• Several theories have been proposed to explain
  this disorder, but research is limited and
  generally weak
  
• Some clinicians suspect biological perhaps
  genetic - 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