Lecture 7: Sex disorders & Paraphilias: Exhibitionism and Frotteuerism

What is normal? Difficulty in defining normal? – Bias in self-reports/clinical impressions

Sexual dysfunctions –  Disruption to ‘normal’ sexual response cycle  Masters and Johnston’s & Kaplan’s model: - Desire phase - Excitement phase - Orgasmic phase - Resolution phase  Should be: persistent & recurrent. Cause clinically significant distress. Not due to medical condition/other psychological illness. Present: during masturbation + sexual activity  Specifiers used to designate onset: - Lifelong - Acquired - Generalised - Situational

Types of disorders –  Interest, desire & arousal: Male hypoactive sexual desire disorder, erectile disorder. Female sexual interest/arousal disorder  Orgasm: delayed ejaculation, premature, female orgasmic disorder  Pain: Genito-pelvic pain/penetration disorder (female) Disorders of interest, desire & arousal –

Female sexual interest/Arousal disorder –  Diminished, absent, or reduced frequency of at least 3 of the following: - Interest in sexual activity - Sexual/erotic thoughts or fantasies - Initiation of sexual activity & responsiveness to partner’s attempts to inititate - Sexual excitement/pleasure - >75% of sexual encounters - Sexual interest/arousal elicited by any internal or external erotic cues - Genital/nongenital sensations - >75% sexual encounters

Male Hypoactive Sexual Desire Disorder –  Persistently deficient or absent sexual fantasies & desires, as judged by clinician  Considerations – age, general/socio-cultural contexts.  Comorbidities: depression, other mental disorders

Erectile disorder – At least 75% sexual occasions. Prevalence: High, accompanies ageing  Inability to attain or maintain erection for completion of sexual activity, or  Marked decrease in erectile rigidity interferes with penetration or pleasure Orgasmic Disorders –

Female Orgasmic Disorder –  On at least 75% of occasions - Marked delay, infrequency, or absence of orgasm - Markedly reduced intensity of orgasmic sensation

Premature Ejaculation –  Persistent/recurrent pattern of ejaculation during partnered sexual activity within 1 minute following penetration  Prevalence: 20-30% at some time

Delayed ejaculation –  Marked delay, infrequency, or absence of orgasm on at least 75% of sexual occasions  Retrograde ejaculation – fluids travel backwards into bladder rather than forwards

Sexual Pain disorder –

Genitopelvic pain/penetration disorder –  Persistent or recurrent difficulties with at least one of following: - Vaginal intercourse/penetration - Marked vulvovaginal or pelvic pain during vaginal penetration or intercourse attempts - Marked fear or anxiety about pain or penetration - Marked tensing of pelvic floor muscles during attempted vaginal penetration  NB: commonly associated with relationship distress  High prevalence of other disorders related to pelvic floor

Substance/medication induced sexual dysfunction

Aetiology of sexual dysfunction –  Biological contributions: - Neurological problems: diabetes, kidney disorders, vascular disease - Prescription medication: Antihypertensives (blood pressure changers) - Illicit drugs and alcohol  Psychological contributions: - Performance anxiety  Social/cultural contributions: views/values/norms or experience of traumatic event (rape)

Treatment –  Providing basic education about sexual functioning  Increasing communication between partners  Eliminating psychologically based performance anxiety  Medications and physical treatments: antidepressants, Viagra etc

Paraphilias – many are comorbid with each other, onset generally adolescence  Defined by intense, persistent, & recurrent sexual attraction to unusual objects or sexual activities, lasting at least 6 months  Diagnosed only when they cause marked distress or impairment (social, occupationally, or other), or engages non-consenting others  Disproportionately men, rare in women  May cause untold suffering for self & sometimes others  Types – - Fetishistic - Transvestic – fantasies, urges, or beh’s involving cross-dressing. Sexual excitement=key - Voyeuristic – watching unsuspecting others undress/have sex - Exhibitionistic – exposing genitals to an unwilling stranger - Frotteuristic – sexual touching of an unsuspecting person - Pedophilic - Sexual sadism – inflicting pain - Sexual masochism – receiving pain

Fetishistic Disorder –  Fantasies, urges, or behaviours involving the use of nonliving objects or nongenital parts of body: causes sig. distress/impairment. Objects not limited to articles of female clothing etc  Onset: adolescence

Voyeuristic –  Fantasies, urges, or behaviours involving the observation of unsuspecting others who are naked, disrobing, or engaging in sexual activity. Person has acted on these urges with a nonconsenting person or the urges or fantasies cause marked distress or interpersonal problems.  Onset: adolescence  Sometimes essential for arousal

Exhibitionistic –  Fantasies, urges or beh’s involving showing one’s genitals to an unsuspecting stranger  Seldom attempt to actually contact stranger  Triggered by anxiety & restlessness as well as sexual arousal  Onset: adolescence  Most cases desire to shock or embarrass  Often remorseful

Frotteuristic –  Fantasies, urges, or beh’s involving touching or rubbing against an unconsenting person  Person has acted on urges with non-consenting person, or urges/fantasies cause clinically significant distress or problems  Onset: adolescence

Pedophilic –  Fantasies, urges, or behaviours involving sexual activity with a prepubescent child. Arousal is as strong or stronger for children than for adults - Person has acted on urges or urges cause clinically significant distress (CSD) - Person is at least age 16yo and 5 years older than the child  Prevalence: victims – up 2.5% of males & 13.5% of females  90% of abusers are male. Typically involve children they know  Most not violent outside of sexual act: children rarely forced/injured  Not all aggressive offenders have pedophilic arousal patterns (ie assault)  Any male can become aroused by erotic pictures of children - Distinction = acting on sexual urges or marked distress

Effects on victim –  ~1/2 children exposed to childhood sexual abuse (CSA) develop symptoms: depression, low SE, anxiety disorders  History of CSA common among adults with mental disorders  Increased likelihood of developing a disorder if: perpetrator threatens child, child blames self, unsupportive family, earlier age, involves intercourse  BUT: families in which abuse occurs often experiencing other problems

Sexual Sadism –  Physical or psychological suffering of another person  Causes CSD, impairment in functioning, or has acted on urges with non-consenting person Sexual Masochism –  Being humiliated, beaten, bound, or made to suffer  Causes CSD or impairment in functioning  Specify with or without asphixiophilia: oxygen deprivation

Typically begins in early childhood: 20-30%

Aetiology of Paraphilias –  Biological - Excess level of male hormones? - Temporal lobe change?  Psychological - Disordered relationships during childhood/adolescence - Physical/sexual abuse - Operant conditioning - OCD – similar paradoxical increase in frequency & intensity - Cognitive distortions

Treatment of paraphilias –  Focus on engaging client… often difficult to do – lack of motivation to do so  CBT: aversion therapy.  Biological - Castration - Medications: hormonal to reduce androgens, antidepressants

Gender dysphoria –  Marked incongruence between one’s experienced/expressed gender and assigned gender  Physical gender inconsistent with sense of identity, no physical abnormalities.  In children: - Desire to be or insistence that he or she is, the opposite gender - Preference for wearing opposite gender clothing - Preference for cross-gender roles in play or fantasy play - Preference for playmates of the opposite gender - Rejection of toys of assigned gender, dislike of own anatomy, etc  In adolescence: - As above – desire to be rid of sex characteristics - Desire to be treated as other gender… conviction of having feelings/reactions of same  1 in 24 000 males, 1 in 150 000

Aetiology –  Genetic/neurobiological: Longer CAG repeats on androgen receptor gene for male-to-female GD. CYP17 gene linked to female-to-male GD. Size of bed nucleus of the stria terminalis consistent with ‘identified’ gender  Psychosocial factors: reinforcement of X-gender beh. received little support

Treatment –  Most common: change body to suit gender. High satisfaction: >75% no regrets.