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Home , Coprophilia, Delayed ejaculation, Klismaphilia, Premature ejaculation, Sexual dysfunction, Voyeurism

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Copyright CEUConcepts, yourceus, LPCAGA, 1 EAPWorks, TMHPros, ACOPSY LPCA, CEUConcepts, yourceus.com, Inc. American College of , and EAP Works present

Psychopathology, Differential Diagnosis, and the DSM-5: A Comprehensive Overview

Copyright CEUConcepts, yourceus, LPCAGA, EAPWorks, TMHPros, ACOPSY 2 This training meets the requirements established under SB 319 /ACT377 and Composite Board Rule 135-12-.01

CE Approved by: ASWB #1239 ASWB #1104 Online

LPCA(6923-30-17M) NBCC (#6762) #6071 Online/YourCEUs.com

Copyright CEUConcepts, yourceus, LPCAGA, EAPWorks, TMHPros, ACOPSY 3 and Differential Diagnosis Course, 8 Modules 1. Module I: Introduction to the DSM-5 (5 core & 2 ethics)

2. Module II: Medical Conditions, and Lifestyle Contributing Concerns (5 core & 1 ethics)

3. Module III: Neurocognitive Disorders, Spectrum and Other Psychotic Disorders, and Bipolar and Related Disorders (5 core & 1 ethics hours)

4. Module IV: Obsessive-Compulsive and Related Disorders, Dissociative Disorders, and Trauma and Stressor Related Disorders (5 hours) Copyright CEUConcepts, yourceus, LPCAGA, 4 EAPWorks, TMHPros, ACOPSY Psychopathology and Differential Diagnosis Course, 8 Modules 5. Module V: Disorders and Depressive Disorders (5 core & 1 ethics hours)

6. Module VI: Somatic Symptom and Related Disorders, Neurodevelopmental Disorders, Elimination Disorders, and Feeding and Eating Disorders (5 hours)

7. Module VII: Paraphilic Disorders, Sexual Functioning Disorders, and Gender Disorders (5 core hours) 8. Module VIII: Substance Use Disorders, Impulse Control and Conduct Disorders, and Personality Disorders

(5 core hours) Copyright CEUConcepts, yourceus, LPCAGA, 5 EAPWorks, TMHPros, ACOPSY Psychopathology, Differential Diagnosis, and the DSM-5: A Comprehensive Overview

Module 8: Sexual Disorders, , and Paraphilic Disorders

(4 Core & 1 Ethics Hours)

Copyright CEUConcepts, yourceus, LPCAGA, EAPWorks, TMHPros, ACOPSY 6 DSM-5, Module 7 - Course Objectives

Upon completion of this program trainees will: 1. Learn the etiology of sexual disorders based on current research 2. Comprehend the complexities of diagnosis for this disorder 3. Grasp appropriate assessment processes for determining sexual disorders, role clarification and differentiation for master’s level clinicians, and appropriate referrals to other professionals in establishing sexual disorders diagnoses 4. Comprehend differential diagnosis from other disorders with similar presentations 5. Apply common specifiers for sexual disorders 6. Learn appropriate treatment strategies based upon diagnosis

Copyright CEUConcepts, yourceus, 7 LPCAGA, EAPWorks, TMHPros, ACOPSY DSM-5, Module 7 - Course Objectives

Upon completion of this program trainees will: 7. Learn the etiology of gender dysphoria disorders based on current research 8. Comprehend the complexities of diagnosis for this disorder 9. Grasp appropriate assessment processes for determining gender dysphoria disorders, role clarification and differentiation for master’s level clinicians, and appropriate referrals to other professionals in establishing gender dysphoria disorders diagnoses 10. Comprehend differential diagnosis with other disorders with similar presentations 11. Apply common specifiers for gender dysphoria disorders 12. Learn appropriate treatment strategies based upon diagnosis

Copyright CEUConcepts, yourceus, 8 LPCAGA, EAPWorks, TMHPros, ACOPSY DSM-5, Module 7 - Course Objectives

Upon completion of this program trainees will: 11. Learn the etiology of paraphilic disorders based on current research 12. Comprehend the complexities of diagnosis for this disorder 13. Grasp appropriate assessment processes for determining paraphilic disorders, role clarification and differentiation for master’s level clinicians, and appropriate referrals to other professionals in establishing paraphilic disorders diagnoses 14. Comprehend differential diagnosis with other disorders with similar presentations 15. Apply common specifiers for paraphilic disorders related disorders 16. Learn appropriate treatment strategies based upon diagnosis

Copyright CEUConcepts, yourceus, 9 LPCAGA, EAPWorks, TMHPros, ACOPSY Your Presenter

Elaine Wilco, MA, LPC

Elaine Wilco is a Licensed Professional Counselor with over 15 years of experience addressing couples concerns, with a specialization in issues related to sex and sexuality. She maintains a private practice in Alpharetta, GA, and provides training and education in issues related to sexuality and intimacy in romantic and marital relationships.

10 Appropriate Role for the Clinician Who is Not A Specialist in

Have a very thorough foundation in the knowledge base related to sex and sexuality, including current trends

Possess a considerable degree of comfort with their own sexuality

Take into account the physical, mental, emotional, relational, cultural, and spiritual aspects of each individual

Know when to refer to a specialist for further assessment and/or treatment

11 What Determines if the Clinician Can Address the Sexual Concerns of the Client?

1. The non-specialist’s knowledge base related to the client’s problem and sexuality in general. 2. Therapists’ skill in dealing with sexuality issues. 3. Observation of clients’ progress - are they responding positively? 4. Therapists’ comfort with addressing sexuality issues and willingness to look at themselves in terms of what sexuality issues might evoke for them. 5. Are there parallels in a client’s life and the therapist’s life that may interfere with treatment, such as a husband who may be having an affair?

12 What Determines if the Clinician Can Address the Sexual Concerns of the Client?

6. The therapist’s willingness to keep “secrets” if requested to do so. 7. The availability of resources for referral and treatment collaboration - OB/GYN physicians, Nurse Practitioners, Pelvic Floor Physical Therapists 9. Other resources the therapist has available for consultation - sexuality listserves made up of experts in the field, knowledgeable colleagues. 10. Personal boundaries - determining areas that may be better addressed by other specialists - for example, sex offenders, BDSM issues, survivors of child and other types of trauma.

13 DSM History - Sexual &

• as a disturbance () – The DSM would not see all references to homosexuality as a disorder removed until publication of the DSM-III-R in 1987

• Gender Identity Disorder – Important changes in DSM-5 – Gender Dysphoria • Consistent with of abnormality requiring “marked distress or impairment of functioning”

• DSM as an evolving system, not a static definition

14 Current & Emerging Trends in Western Society Societal/Cultural/Religious

• Sexting • Piercings—ex. Prince Albert • Expansion of ideas of roles, boundaries, experimentation with multiple sexual identities and activities • Hooking up, FWB (Friends with Benefits) • Extramarital affair websites, including Ashley Madison • • “” • Preference of fantasy modes of expressing sexuality (e.g., avatar sex) over person to person, real-life sexual intimacy

15 Current & Emerging Trends in Western Society Societal/Cultural/Religious • Sexuality for all phases of adult life cycle: sexually active older adults • The little blue pill (Viagra, Levitra, Cialis) • Other medical procedures for sexual concerns: replacement therapy for men and women, penile implants • Increased cultural diversity with multiple viewpoints on expressions of sexuality and normative sexual practices • Sexuality as facet of religious practices within culturally separate groups • pledges • Specific cultural practices such as Female Genital Cutting and conflicts with Western ideas of human rights

16 Current & Emerging Trends in Western Society Societal/Cultural/Religious

• Compulsive sexuality, including internet

– DSM-5—no diagnosis of

– ICD 10—Excessive Sexual Drive—defined under Other not due to a substance or known physiological condition

17 Experiencing Sexuality via Fantasy

______Thinking Feeling Fantasy

Potential Problems with Fantasy

1. Too much time in fantasy world 2. Fantasizing about improper sexual partners 3. May conflict with values/beliefs 4. Person may be less centered and involved

18 Complications of 21st Century Sexual Expression

Paraphilic Disorders versus fetishism

Paraphilic Disorders versus “kink”

“Kink” versus Intimate Partner Violence

Intimate partner violence is: – Non-consensual – Not negotiated, so no negotiated end – Intended to exploit – Leaves individuals traumatized

19 Addressing the Emergence of Kink

• Do not assume that rough sex is non-consensual. • Do not assume that unusual sex is pathological. • Do not assume that partners are kinky/poly/compliant just because it is what their partner wants. • Do not assume that anyone’s looks the way you expect it to. • ASK respectful, intelligent QUESTIONS.

20 Understanding Sexuality

21 Components of Sexuality

1. 100%------100% Homosexual Heterosexual 2. Gender Identity 3. Appearance 4. Behavior

22 Kinsey Sexual Orientation Scale

23 The Kinsey Scale in a Gender Fluid World

24 Components of Sexual Life

1. Biological Sexuality 2. Gender Identity <-----Gender Socialization 3. Gender Expression 4. <-----Sexual Socialization 5. Sexual Expression 6. Relational Identity <-----Relational Socialization 7. Relational Expression

25 Components of Sexual Life

Gender Identity: an individual's self-identification as man, woman, gender queer, cisgender, , non- gendered or any other identity category

Sexual Identity: refers to the gender(s) that a person is emotionally, physically, romantically, and erotically attracted to

Relational Identity: refers to the nature of the relationships preferentially entered into: monogamous, nonmonogamous, polyamorous

26 Partnered Sexual Problems and Sex Therapy

27 Sexual Concerns in Today’s Society

“A conservative estimate would indicate half the [in this country] as either presently sexually dysfunctional or imminently so in the future” (, 1970). Sex therapists were saying that at least 50% of marriages have serious sexual concerns, and that if the truth were actually known, it would likely be closer to 75%.

28 Sexual Concerns in Today’s Society

• Performance Anxiety • • Sexual Pain Problems • Problems • Problems • Desire Problems • Sexual Addiction/Compulsivity

29 Sexual Dysfunctions

Sexual dysfunctions include , erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, genitopelvic pain/penetration disorder, male hypoactive disorder, premature (early) ejaculation, substance/- induced sexual dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction. Sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience sexual pleasure. An individual may have several sexual dysfunctions at the same time. In such cases, all of the dysfunctions should be diagnosed.

30 Sexual Concerns in Today’s Society

What are the most common sexual disorders for men?

1. Ejaculation disorders 2. Erectile disorders 3. Inhibited sexual desire

31 Sexual Concerns in Today’s Society

What are the most common sexual disorders for women?

1. Low sex drive 2. Arousal Disorders 3. Difficulty with 4. Painful intercourse

32 Prevalence of Women’s Sexuality Concerns

Survey by Nusbaum, Gamble, Skinner, & Heiman—964 of 1480 responded

• 98.8% reported one or more concerns • Lack of interest 87.2% • Difficulty with orgasm 83.3% • Inadequate lubrication 74.7% • 71.7% • concerns 68.5%

33 Prevalence of Women’s Sexuality Concerns…con’t.

• Unmet sexual needs 67.2% • Needing information about sexual issues 63.4% • Over half reported physical or sexual abuse • More than 40% reported sexual coercion at some point in their lives.

Nusbaum, M.R., Gamble, G., Skinner, B. & Heiman, J. (March 2000). The high prevalence of sexual concerns among women seeking routine gynecological care. J Fam Pract. 49 (3), 229-32.

34 Anorgasmia

Primary anorgasmia is frequently the result of one or more of the following: 1) Lack of information and/or awareness about sex and self, 2) Communication problems within the sexual relationship, 3) Fears, , or performance anxiety

Secondary anorgasmia can be the result of certain illnesses such as and , the side effects of , or certain types of or . Relationship problems can also be a factor.

Situational anorgasmia may result from physical issues such as fatigue or medication side effects or may be connected to relationship issues (anger at partner, lack of attraction to partner, etc.).

35 About Anorgasmia

• Study: previous 12 months, 10% of women rarely or never had an orgasm.1 • There’s more to being happy than having . Studies show intimacy & connection with partners are strongest predictors of sexual satisfaction.2

1) Laumann, et al., 1994 2) Berman, Berman, & Schweiger, 2006

36 Causes of Anorgasmia

• Lifestyle issues—being busy • Lack of information and/or awareness • Fears • Guilt • Performance anxiety—the tyranny of the “shoulds” • Medical, Surgical, & Disabling Conditions • Medications

37 Additional Causes of Anorgasmia

• Pain • Communication problems • Lack of attraction to partner • Resentment toward partner • Boredom

38 Sexual Dysfunctions Code Disorder Category

F52.32 Delayed Ejaculation

Criteria: 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. D. The sexual dysfunction is not better explained by a nonsexual 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. 39 Sexual Dysfunctions Code Disorder Category

F52.32 Delayed Ejaculation

Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

40 Sexual Dysfunctions Code Disorder Category

F52.21 Erectile Disorder

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. 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.

41 Sexual Dysfunctions Code Disorder Category

F52.21 Erectile Disorder

Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

42 Sexual Dysfunctions Code Disorder Category

F52.31 Female Orgasmic Disorder

Criteria:

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 significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

43 Sexual Dysfunctions Code Disorder Category

F52.31 Female Orgasmic Disorder

Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify if: Never experienced an orgasm under any situation.

Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

44 Sexual Dysfunctions Code Disorder Category

F52.22 Female Sexual Interest/Arousal Disorder

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 nongenital sensations during sexual activity in almost all or all (approximately 75%-100%) sexual encounters (in identified situational contexts).

45 Sexual Dysfunctions Code Disorder Category

F52.22 Female Sexual Interest/Arousal Disorder

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 nonsexuai 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.

Specify whether:

Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

46 Sexual Dysfunctions Code Disorder Category

F52.22 Female Sexual Interest/Arousal Disorder

Specify whether:

Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity:

Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

47 Sexual Dysfunctions Code Disorder Category

F52.6 Genito-/Penetration Disorder

Criteria: 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. 48 Sexual Dysfunctions Code Disorder Category

F52.6 Genito-Pelvic Pain/Penetration Disorder

Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms in Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

49 Sexual Dysfunctions Code Disorder Category

F52.0 Male Hypoactive Sexual Desire Disorder

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.

50 Sexual Dysfunctions Code Disorder Category

F52.0 Male Hypoactive Sexual Desire Disorder

Specify whether: Lifelong: The disturbance has been present since the Individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity: Mild: Evidence of mild distress over the symptoms in Criterion A. Moderate: Evidence of moderate distress over the symptoms In Criterion A. Severe: Evidence of severe or extreme distress over the symptoms in Criterion A.

51 Sexual Dysfunctions Code Disorder Category

F52.4 Premature (Early) 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. Note: Although the diagnosis of premature (early) ejaculation may be applied to individuals engaged in nonvaginal sexual activities, specific duration criteria have not been established for these activities. 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 significant stressors and is not attributable to the effects of a substance/medication or another medical condition.

52 Sexual Dysfunctions Code Disorder Category

F52.4 Premature (Early) Ejaculation

Specify whether: Lifelong: The disturbance has been present since the individual became sexually active. Acquired: The disturbance began after a period of relatively normal sexual function.

Specify whether: Generalized: Not limited to certain types of stimulation, situations, or partners. Situational: Only occurs with certain types of stimulation, situations, or partners.

Specify current severity: Mild: Ejaculation occurring within approximately 30 seconds to 1 minute of vaginal penetration. Moderate: Ejaculation occurring within approximately 15-30 seconds of vaginal penetration. Severe: Ejaculation occurring prior to sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration

53 Substance/Medication-Induced Sexual Dysfunction

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 or withdrawal or after exposure to 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 . E. The disturbance causes clinically significant distress in the individual.

54 Substance/Medication-Induced Sexual Dysfunction

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention.

Specify if: With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication. With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal. With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.

Specify current severity: Mild: Occurs on 25%-50% of occasions of sexual activity. Moderate: Occurs on 50%-75% of occasions of sexual activity. Severe: Occurs on 75% or more of occasions of sexual activity.

55 Other Specified Sexual Dysfunction F52.8

This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class. The other specified sexual dysfunction category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific sexual dysfunction. This is done by recording “other specified sexual dysfunction” followed by the specific reason (e.g., “sexual aversion”).

56 Unspecified Sexual Dysfunction F52.9

This category applies to presentations in which symptoms characteristic of a sexual dysfunction that cause clinically significant distress in the individual predominate but do not meet the full criteria for any of the disorders in the sexual dysfunctions diagnostic class. The unspecified sexual dysfunction category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific sexual dysfunction, and includes presentations for which there is insufficient information to make a more specific diagnosis.

57 Partnered Sexual Problems

58 Gathering Information During Assessment of Sex Related Disorders

• All components of a thorough biopsychosocial assessment should be addressed • Gather present and past history of gendered, sexual, and relational life and interactions using tools and approaches for gathering sensitive sexual material • Family and cultural elements of sexual life should be explored in a culturally sensitive way • Family history of problems with mental illness, corporal punishment, and/or traumatic events • Gather medical history – illness and , history of use of medications, nutritional supplements, toxic substance exposure • Address client’s goals and expectations for his/her sexual life

59 Assessment Tips

• Be slow, gentle and patient in exploration • Model comfort and security in addressing sexual material • Normalize detailed exploration of sexual, gendered, and relational life • Go from least threatening to most threatening • Go from past to present • Go from general to specific • While assessing, begin to prepare the client for engaging in sex therapy, if it is indicated

60 Sex Therapy

• Definition—the direct, symptomatic treatment of sexual dysfunctions. Initially involved brief, time-limited directive counseling aimed at symptom removal rather than attainment of insight, uncovering of repressions, or resolution of unconscious conflict.

61 Sex Therapy

Basic Principles ▪ 1) Mutual Responsibility—all sexual dysfunctions are shared disorders ▪ 2) Information and Education ▪ 3) Attitude Change ▪ 4) Eliminating Performance Anxiety ▪ 5) Increasing Communication and Effectiveness of Sexual Technique ▪ 6) Changing Destructive Lifestyles and Sex Roles ▪ 7) Prescribing Changes in Behavior

62 Postmodern Sex Therapy

• Deals with more complex and chronic sexual issues 1) Chronic illness 2) Drug effects 3) Sexual desire disorders 4) Unresolved relationship issues 5) Cultural issues 6) Often used in conjunction with surgical, mechanical, or medical interventions

63 Specific Suggestions: Sexual Problem History Abbreviated Version

• Description of current problem (expressed and observed) • Onset and course of problem, with precipitants, if any known • Patient’s concept of factors that may have caused and maintained the problem • Past (and current) treatment and outcome – Medical evaluation • Is the client currently on any medications?* • History of illness or injury – Professional help • Current expectancies and goals of treatment

* Very important—meds can have serious sexual side effects.

64 Medications, Substances and Medical Complications

Medications are a MAJOR cause of sexual problems.

SSRIs--Prozac, Zoloft, Paxil, Celexa increase and are associated with decreased desire, delayed ejaculation in men, and anorgasmia in men and women.

Even unsuspected over-the-counter drugs such as Tagamet can cause problems.

Alcohol, tobacco and may be impediments to sexual functioning.

65 Medications, Substances and Medical Complications

Numerous medical concerns may interfere with sexual functioning:

• , ( & peripheral ) • Diabetes • cancer • • • Depression • Anxiety

Also, menopause may have sexual effects, as well as issues related to normal aging

66 Tips for Assessment and Counseling

• Avoid value laden questions:“Are you sexually active? What is your marital status?” • Ask what the client thinks is creating the problems for which help is being sought. • Include client and his/her partner, when possible. • Be sensitive when asking potentially threatening or embarrassing questions. • Acknowledge awareness of the client’s distress. • Use your therapeutic mistakes/oversights as valuable lessons to enhance future practice.

67 Specific Considerations to Assess for Counseling/Therapy

• Beliefs about Sex – American idea of sex (performance driven, simultaneous orgasms, ideas of sexual interaction from pornography) – Expectations of men and women – Other • Background • Culture • Religious/Moral Beliefs • Age • Social Situation

68 The PLISSIT Model for Counseling

• Permission--Bringing up the topic • Limited Information--Giving facts and dispelling myths. • Specific Suggestions—Addressing the specific concern • Intensive Therapy—Referring to a sex therapist or psychotherapist—word of mouth or AASECT.org • NOTE: 70% of problems can be helped with the first three

69 P=Permission Suggestions for Bringing up the Topic of Sexuality

1. Many people have concerns about...... What are yours? 2. What effects has this illness (or this relationship issue or whatever they are seeing you for) had on your sexuality? 3. We have information at our facility on a number of topics you might want to know about, including diet, exercise, hypertension, sexuality, etc. 4. How did you learn about...... ? 5. How did you feel about...... ? 6. What messages did you get regarding...... ?

70 P= Permission Bringing up the Topic

• “Some of these medications may cause changes in your sexuality. If you notice any changes that bother you, come back and let’s talk about it. We can prepare you for discussions with your physician to make adjustments in the meds.”

• “What other information do you think I might need to know in terms of you health care?” Or is there anything else I haven’t asked about that you’d like me to know? These types of questions are helpful in determining if there is a topic of concern that hasn’t been raised.

71 Limited Information

• “Research indicates that 95-99% of men masturbate. What have your experiences been with this?” • “Changes in sexual interest is an extremely common experience in today’s busy world.” • “Research shows age doesn’t diminish need and desire for sex, regular sexual activity is standard when a partner is available, and most aging people believe sex contributes to physical and psychological health.”

72 Treatment of Anorgasmia

• Physical exam with lab work-- function, , progesterone, and fasting blood . Elevated prolactin levels (indication of lots of conditions including pituitary adenoma and Cushing’s Disease).

73 Treatment of Anorgasmia— The PLISSIT Model

• Permission – How has ______affected your sexuality? – Use words the patient understands. – Determine if the anorgasmia is primary, secondary, or situational. – Ask for a word picture of her experience. – Validate your understanding of what she’s telling you.

74 PLISSIT--Permission continued

• Explore self-concept, body image, values, knowledge, beliefs, cultural influences, family messages, current practices, feelings about touching body, past experiences, expectations about what is supposed to happen, fears involved, reactions of and to partner, nature of relationship, religious background. • Ask questions in a way that normalizes the experience-- ex. “What happens when you touch yourself? • Ascertain the meaning of the experience to her, to a partner. • Determine her expectations and the anticipated impact on her life.

75 PLISSIT--Permission continued

• Give general information related to anorgasmia (meds, thinking vs. feeling, with intercourse, societal & cultural influences). • Address myths, misconceptions, and fears. • Discuss anatomy and . • Give information about women’s descriptions of what an orgasm feels like.

76 PLISSIT--Specific Suggestions

• Complete the Sexual Problem History. • Recommend books and videotapes. • Teach about the pubococcygeus muscle and Kegel exercises. • Discuss use of a --advantages and possible drawbacks. • Suggest increasing awareness of turn-ons and time for self-exploration.

77 PLISSIT--Specific Suggestions Related to Medication Issues

• Wait 4-6 weeks for sexual side effects to resolve • Lower SSRI dose • Alter timing of daily dose • Drug holidays with SSRIs • Changing medication – Wellbutrin (), Buspar (), Cymbalta (), Lexapro (), Remeron () • Adding another medication – Wellbutrin, Buspar, Periactin (Cyproheptadine), Amantadine (Symmetrel)

78 Pelvic Pain Disorders

• Because pelvic pain disorders may be uncovered during a sexuality assessment, it is important to be able to recognize them. However, unless you are a specialist in this area, you would simply make an appropriate referral for additional specialized help.

79 Pelvic Pain Multiple Diagnoses

▪ Dyspareunia ▪ ▪ ▪ Vulvar Vestibulitis

80 Persistent Genital Arousal Disorder (aka Persistent Syndrome)

A complex and distressing problem in women characterized by feelings of spontaneous and persistent physiological genital arousal that occur without any conscious awareness of sexual desire. (Goldmeier & Leiblum, 2006; Leiblum & Nathan, 2001).

Prevalence unknown.

Causes unknown. May be a blend of psyche and soma. Has some neurologic similarities to Restless Leg Syndrome. No single treatment is recommended. 81 Male Sexuality

82 Erection Problems

Masters and Johnson reported that his is a big problem for men

Popularity of Viagra, Cialis, Levitra

83 Erection Problems--Causes

1. Vascular Insufficiency 2,000,000 (arteriosclerosis, hypertension, antihypertensive medication) 2. Diabetes Mellitus 1,500,000 3. Radical Surgeries 650,000 (prostatectomies, colostomies, etc.) 4. Trauma 400,000 ( injuries, etc.) 5. Side effects from medications and alcohol (tranquilizers, , antihypertensives, etc.) Numbers unknown •

84 Erection Problems--other causes

• Depression • Emotional conflict • Repressed anger • Traumatic experiences • Sex center not turned on • Low testosterone or cells’ inability to use testosterone • Thinking/Anxiety

85 Erection Problems

• May be first sign of undiagnosed diabetic disorder or cardiac disease--evaluation is very important. • Even in cases involving a large physical component, psychological and relational issues may still be major factors to consider.

86 Assessment and Treatment of Erection Problems

• Sexual Problem History • See Erection Guidelines • Physical, psychological, and relational assessment – Evaluation by a sex-friendly urologist • Treatments based on assessment • Referral for counseling if indicated

87 Treatment of Erection Problems Specific Suggestions

• Medications--Viagra, Cialis, Levitra • External vacuum devices, hormonal therapy, penile injections, and intraurethral pellet therapy • Penile implants

88 Viagra Side Effects

• Headaches—1 of 10 in trials • Seeing Blue—temporary vision problems—3% • Blackouts—sudden drops in BP: risk factor with nitroglycerin or antihypertensives • —a theoretical risk • Coital Coronaries—could mask life-threatening conditions • Abuse?—Long term effects unknown • Relationship Issues

89 Non-Demand Interventions for Various Sexual Problems

• Sensate Focus—a sex therapy technique • Sensual • Sex Surrogates (where legal)

90 The most common male sexual problem

• Text Definitions: – 1) Inability to control ejaculation before, during, or shortly after intromission – 2) Ejaculation before the individual desires it

• Other Definitions – Rapid ejaculation that interferes with a relationship

• Possible Causes – Organic/Psychogenic/Interaction

91 Premature Ejaculation Interventions

• Sex Therapy Interventions – 1) Stop-Start Technique – 2) Squeeze Technique • Other Interventions – Slow down – Ejaculate more often – Kegel exercises – Reduce anxiety – Change positions • Other Intervention – Pharmacologic—Prozac/Paxil

92 Hypoactive Sexual Desire

93 Hypoactive Sexual Desire Magnitude of the Problem

Among the most common problems seen in therapists’ offices Perhaps 25% of all Americans 1/3 of women 1/5 of men Difficult sexual issue to address Many possible causes Causes may overlap

94 Issues in Low Desire

1. Desire discrepancy is frequently the presenting issue.

2. One or both partners may want a quick resolution.

3. Anger, blame, shame, and a sense of hopelessness are often present.

95 Causes of Desire Problems

1. Differences in baseline sexual desire a. Initial desire biochemically based--PEA, dopamine, other. Typically lasts 18-36 months. • PEA--phenylethylamine--the “love drug”--in chocolate • Dopamine—Pleasure

b. Importance of Testosterone levels in men and women.

96 Causes of Desire Problems

2. Fatigue 3. Sex Negative Religious Orthodoxy 4. Depression 5. Anhedonia 6. or aversions 7. Triggering of childhood trauma 8. Fear of loss of control over sexual urges 9. Hidden sexual deviation

97 Causes of Desire Problems

10. Fear of 11. Widower’s or Widow’s Syndrome 12. and Neurotransmitters a. Measuring levels--blood vs. saliva b. Free (bioavailable) testosterone--not bound to carrier proteins, particularly Sex Hormone Binding Globulin. Declines with aging, chronic illness, infection, smoking, trauma, etc. c. Menopause in women, andropause in men

98 Causes of Desire Problems

13. Medications a. Are a MAJOR cause of sexual problems. b. SSRIs--Prozac, Zoloft, Paxil, Celexa increase serotonin and are associated with decreased desire, delayed ejaculation in men, and anorgasmia in men and women. c. Even unsuspected over-the-counter drugs such as Tagamet can cause problems.

99 Causes of Desire Problems

14. Lifestyle Issues Alcohol, marijuana, lack of exercise, lack of rest, and poor nutrition can contribute.

100 Causes of Desire Problems

15. Relationship Issues a. Lack of attraction to partner 1) Weight gain 2) Body changes of aging 3) Disfiguring injuries or surgeries 4) Pregnancy 5) Boredom 6) The Coolidge Effect

101 Causes of Desire Problems

Relationship Issues……continued b. Communication problems c. Poor social and relationship skills d. Fear of closeness and vulnerability e. Passive-aggressive issues f. Marital conflict, unresolved anger g. Obligatory sex or mechanical, scripted, impersonal sex h. The Madonna-Prostitute Syndrome

102 Testosterone Replacement--A Complex and Controversial Practice

Replacement In Women a. Only after documentation of clinical need b. Short term basis only--long term safety not established c. Potential for masculinizing effects d. Concern about potentiation of cancer and heart disease. Oral preparations have potential of liver toxicity and raising bad cholesterol levels.

103 Testosterone Replacement

Replacement In Men a. Must be confirmed by hormone assay. b. May continue lifelong with monitoring. c. In younger men, deficiency is usually due to underlying hypothalamopituitary or testicular disorders. d. Deficiency is an uncommon cause of . e. Is not an anti-aging elixir.

104 Purported Drug/Herbal Remedies for Decreased Desire in Women

Viagra--Pfizer stopped studies on women Avlimil--herbal pill; no empirical evidence of effectiveness Zestra--arousal oil; claims to reverse side effects of SSRI meds Wellbutrin--an antidepressant —failed FDA clinical trials; has now been approved!

105 Other Remedies

Altering lifestyle habits--alcohol, smoking, diet, exercise, rest Continuing sexual experiences

106 Other Remedies

• Pay attention to relationships • Make time • Slow down and allow time • Change routine • Have dates • Romantic weekends • Loving behaviors • Getting turned on after starting

107 Medical, Surgical, and Disabling Conditions

a. Diabetes--sexual symptoms may precede diagnosis; many problems b. Heart Disease--sexual symptoms may precede diagnosis; fears c. Hypertension--medications d. Hysterectomy--role changes; decreased testosterone e. Mastectomy--body image; cancer medications f. Prostatectomy--erection and ejaculation changes g. Arthritis--pain; position changes h. --memory changes; position changes; fears i. Depression--lack of desire; medications

108 Gender Dysphoria

109 Gender Dysphoria

• Exact cause of gender dysphoria is not fully understood.

• Some correlation of final gender identity outcome with the degree of prenatal production.

• There is “growing evidence showing that (prenatal) testosterone exposure contributes similarly to the development of other human behaviors that show sex differences, including sexual orientation, core gender identity and some, though not all, sex-related cog nitive and personality characteristics.”

Source: Hines, Melissa, Gender Development and the Human Brain, Annual Review of Neuroscience 2011 34:69-88

110 Gender Dysphoria

Gender assignment refers to the initial assignment as male or female. This occurs usually at birth and, thereby, yields the "natal gender." Gender-atypical refers to somatic features or behaviors that are not typical (in a statistical sense) of individuals with the same assigned gender in a given society and historical era; for behavior, gender- nonconforming is an alternative descriptive term. Gender reassignment denotes an official (and usually legal) change of gender. Gender identity is a category of social identity and refers to an individual's identification as male, female, or, occasionally, some category other than male or female. Gender dysphoria as a general descriptive term refers to an individual's affective/ cognitive discontent with the assigned gender but is more specifically defined when used as a diagnostic category.

111 Gender Dysphoria

Transsexual denotes an individual who seeks, or has undergone, a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital (). Gender dysphoria refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. Although not all individuals will experience distress as a result of such incongruence, many are distressed if the desired physical interventions by means of hormones and/or surgery are not available. The current term is more descriptive than the previous DSM-IV term gender identity disorder and focuses on dysphoria as the clinical problem, not identity per se.

112 Gender Dysphoria Gender Dysphoria in Children F64.2 A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender). 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire: or in girls (assigned gender), a strong preference for wearing only masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one’s sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.

113 Gender Dysphoria Gender Dysphoria in Children F64.2 B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning. Specify if; With a disorder of sex development (e.g., a congenital adrenogenital disorder such as E25.0 congenital adrenal hyperplasia or E34.50 androgen insensitivity syndrome). Coding note: Code the disorder of sex development as well as gender dysphoria

Gender Dysphoria in Adolescents and Adults F64.1 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. 114 Gender Dysphoria

Gender Dysphoria in Adolescents and Adults F64.1 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. Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such as E25.0 congenital adrenal hyperplasia or E34.50 androgen insensitivity syndrome). Coding note: Code the disorder of sex development as well as gender dysphoria. Specify if: Posttransttion: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen—namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, in a natal male; mastectomy or phalloplasty in a natal female).

115 Other Specified Gender Dysphoria (F64.8)

This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The other specified gender dysphoria category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for gender dysphoria. This is done by recording “other specified gender dysphoria” followed by the specific reason (e.g., “brief gender dysphoria”). An example of a presentation that can be specified using the “other specified” designation is the following: The current disturbance meets symptom criteria for gender dysphoria, but the duration is less than 6 months.

116 Unspecified Gender Dysphoria (F64.9)

This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The unspecified gender dysphoria category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for gender dysphoria, and includes presentations in which there is insufficient information to make a more specific diagnosis.

117 Paraphilic Disorders

118

• Exact cause of paraphilias not fully understood.

• Some research indicates that there may be some neurological abnormalities in the areas of the brain also responsible for Obsessive- Compulsive Disorders for some of the paraphilias

• Other researchers have proposed that associations occur between the object(s) of the paraphilias and the pleasure of sexual arousal, and those associations become reinforced as they are repeated

• With increased sexual freedom, people may experiment with non- traditional behaviors as part of sexual exploration and this must be differentiated from pharaphilias and paraphilic disorders

119 Paraphilias

The term denotes any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. There are specific paraphilias that are generally better described as preferential sexual interests than as intense sexual interests. Some paraphilias primarily concern the individual's erotic activities, and others primarily concern the individual's erotic targets. Examples of the former would include intense and persistent interests in spanking, whipping, cutting, binding, or strangulating another person, or an interest in these activities that equals or exceeds the individual's interest in copulation or equivalent interaction with another person.

120 Paraphilias

Examples of the latter would include intense or preferential sexual interest in children, corpses, or amputees (as a class), as well as intense or preferential interest in nonhuman animals, such as horses or dogs, or in inanimate objects, such as shoes or articles made of rubber. A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention.

121 Paraphilias

NON-COERCIVE PARAPHILIAS

• Fetishism • • and Urophilia • Transvestism and Crossdressing • Autoerotic Asphyxiophilia

122 Paraphilias

COERCIVE PARAPHILIAS

• (Exposing one’ s self) • (Rubbing up against people) • Scatolophilia (Making obscene phone calls) • (Fantasies of sex with animals) • (Sex with dead bodies) • (Peeping Tom behaviors) • (Sex with young children)

123 DSM-5 - Paraphilic Disorders

• Recurrent, intense, sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects, the suffering or humiliation of oneself or one’s partner, or children or other non- consenting persons

• Diagnosis is generally limited to cases including: – A time period extending past 6 months – Subjective distress in response to these desires – Impairment in functioning

124 Paraphilic Disorders

Must have acted on these sexual urges with a non- consenting person, or the sexual urges cause…. clinically significant distress or impairment.

125 Paraphilic Disorders Code Disorder Category

F65.3 Voyeuristic Disorder

Criteria: 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. 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. C. The individual experiencing the arousal and/or acting on the urges is at least 18 years of age. Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in voyeuristic behavior are restricted. In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment. 126 Paraphilic Disorders Code Disorder Category

F65.2 Exhibitionistic Disorder

Criteria: 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. Specify whether: Sexually aroused by exposing genitals to prepubertal children; Sexually aroused by exposing genitals to physically mature individuals; Sexually aroused by exposing genitals to prepubertal children and to physically mature individuals Specify if; In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to expose one’s genitals are restricted. In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment 127 Paraphilic Disorders Code Disorder Category

F65.81 Frotteuristic Disorder

Criteria: A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching or rubbing against a nonconsenting 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.

Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to touch or rub against a nonconsenting person are restricted. In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.

128 Paraphilic Disorders Code Disorder Category

F65.51 Sexual Masochism Disorder

Criteria: A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or othenwise made to suffer, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: With asphyxiophilia: If the individual engages in the practice of achieving sexual arousal related to restriction of breathing.

Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in masochistic sexual behaviors are restricted. In full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at last 5 years while in an uncontrolled environment

129 Paraphilic Disorders Code Disorder Category

F65.52

Criteria: A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another 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.

Specify if: In a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in sadistic sexual behaviors are restricted. In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.

130 Paraphilic Disorders Code Disorder Category

F65.4 Pedophilic Disorder

Criteria: 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. C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A. Note: Do not include an individual in late involved in an ongoing sexual relationship with a 12- or 13-year-old. Specify whether: Exclusive type (attracted only to children) Nonexclusive type Specify if: Sexually attracted to males; Sexually attracted to females; Sexually attracted to both Specify if: Limited to

131 Paraphilic Disorders Code Disorder Category

F65.0 Fetishistic Disorder

Criteria: A. Over a period of at least 6 months, recurrent and intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s), as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas 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 puφose of tactile genital stimulation (e.g., vibrator).

Specify: Body part(s) Nonliving object(s) Other

Specify if: in a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to engage in fetishistic behaviors are restricted. in full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment. 132 Paraphilic Disorders Code Disorder Category

F65.1 Transvestic Disorder

Criteria: A. Over a period of at least 6 months, recurrent and intense sexual arousal from crossdressing, as manifested by fantasies, urges, or behaviors. B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if: With fetishism: If sexually aroused by fabrics, materials, or garments. With autogynephilia: If sexually aroused by thoughts or images of self as female.

Specify if: in a controlled environment: This specifier is primarily applicable to individuals living in institutional or other settings where opportunities to cross-dress are restricted, in full remission: There has been no distress or impairment in social, occupational, or other areas of functioning for at least 5 years while in an uncontrolled environment.

133 Paraphilic Disorders Code Disorder Category

F65.89 Other Specified Paraphilic Disorder

This category applies to presentations in which symptoms characteristic of a paraphilic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the paraphilic disorders diagnostic class. The other specified paraphilic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific paraphilic disorder. This is done by recording “other specified paraphilic disorder'’ followed by the specific reason (e.g., “zoophilia”). Examples of presentations that can be specified using the “other specified” designation include, but are not limited to, recurrent and intense sexual arousal involving telephone scatologia (obscene phone calls), necrophilia (corpses), zoophilia (animals), coprophilia (), (), or urophilia (urine) that has been present for at least 6 months and causes marked distress or impairment in social, occupational, or other important areas of functioning. Other specified paraphilic disorder can be specified as in remission and/or as occurring in a controlled environment. 134 Paraphilic Disorders Code Disorder Category

F65.9 Unspecified Paraphilic Disorder

This category applies to presentations in which symptoms characteristic of a paraphilic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the paraphilic disorders diagnostic class. The unspecified paraphilic disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific paraphilic disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.

135 Ethics, Culture, Sexuality, and Diagnosis

136 Bias of the Dominant Culture

The ideas and beliefs that form the foundation of the counseling professions are so fundamentally infused with Western thought that the counseling itself risks being just another mechanism for imposing the values of the dominant culture on those who are different.

Source: Sue and Sue

137 Bias of the Dominant Culture

"Mental health practice has been characterized as primarily a White middle-class activity that values rugged individualism, individual responsibility, and autonomy."

Source: Sue and Sue

138 Value Content Differences

Cultural differences in such emotionally loaded areas as sexuality, sexual orientation, family structure, death and dying will show up frequently in cross-cultural counseling.

139 SEXUAL MINORITY CLIENTS

140 Sexuality Factoid

In a national survey, 90% of men aged 18-44 considered themselves to be heterosexual, 2.3% as homosexual, 1.8% as bisexual, and 3.9% as 'something else'

Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Advance data from vital and health statistics; no 362. Hyattsville, MD: National Center for Health Statistics. 2005.

141 Changes in the DSM-5

• Changes to the most recent DSM – Labeling – eg: Voyeurism » Voyeuristic Disorder • What this implies about fetishes, exhibitionism, voyeurism, etc.

• DSM also limits diagnosis – non-consenting person, or – clinically significant distress

142 Sexual Minority Groups

• Gay • Lesbian • Bisexual • Transexual • • “Kink” • Paraphilias, Fetishes • Polyamory

143 Guiding Considerations

What does your profession’s code of ethics say with regard to providing mental health services cross- culturally?

144 Models of Assimilation

A+b+c = A White bread model A+b+c = A' Melting pot model A+b+c = A'(a'b'c') Quasi-assimilation model A+b+c = A+b+c Transitive model A+b+c = A'B'C‘ Reconstructionist model A+b+c = X'a'b'c‘ Pseudo-assimilation model

Source: Leah Wing

145 We live at the end of a century in which the competitive economic market has demonstrated its powerful ability to shape the dominant consciousness of the planet. That market consciousness has convinced many that the highest goal of life is to consume, that the proof of one's own self-worth is how much power and money one has at one's disposal, that the "natural" inclination of each person is toward selfishness and egotism, that every other person is a potential rival for scarce economic or emotional resources, that societies should be constructed primarily to protect the individual so that s/he may pursue her own self- interest without external constraints, that progress means the increasing scientific conquest of nature and its transformation into forms that can be used or sold to others, that the goal of knowledge is to increase control and domination of the world, and that the rational way to look at others is in terms of what they can do for you to advance your own agenda.

From, Michael Lerner, Spirituality in America, Tikkun, 9-10/98

146 There has never been nor could there ever be an ethically and politically neutral definition of mental health. When therapists argued that they were merely seeking to empower individuals so that they could make their own choices, they were already deeply enmeshed in the market-oriented way of viewing society, one that privileged individuals and imagined that they could be healthy without regard to the quality of human relations and social realities around them. In this way, the definition neatly replicated the logic of the competitive market itself, which saw human beings as isolated monads equally fit to compete against each other for societal goods.

From Psychotherapy Versus Managed Care, Tikkun 11-12/94

147 Values

Values are deeply held cognitive and emotional constructs that 1) help people define themselves, their lives and their actions, 2) provide positive emotional support for adhering to the cultural beliefs, and 3) provide limits and sanctions for any aberrant behavior that might create conflict and the breakdown of group cohesion.

148 Culturally Aware

- Know your own background - Know how assumptions and biases from your own background shape how you see and interact with the world - Understand how assumptions and biases affect the manner in which therapeutic experience is shaped - Know your own limitations in working cross-culturally

149 Culturally Aware

- Cognitive effects of cultural bias - Emotional effects of cultural bias

150 Culturally Aware

Tolerating the discomfort of having one's own deeply held personal – and/or professional - values challenged by someone who may partially or wholly disagree with and reject those values.

151 Culturally Knowledgeable

- Know the biases of dominant culture - Understand the cultural elements of the client that are relevant to the definition of problems and solutions

152 Culturally Knowledgeable

- Have a solid background in the relevant practice literature concerning practice with non-dominant cultural groups - Understand the institutional and cultural barriers that impede minority groups from using mental health services

153 Culturally Skilled

- Possess a wide range of skills to use in interventions with clients from different cultural backgrounds - Be fluent with communication (verbal and non-verbal) that is well-received and understood by the clients within their own cultural experience.

154 Culturally Skilled

- Intercede on the behalf of the client to address the flaws in the dominant system - Help the client to bridge the cultural differences in a dialogue with the dominant culture

155