Sexual Dysfunctions, Paraphilic Disorders &

Gender Dysphoria
ABNORMAL PSYCHOLOGY
PRESENTED BY: JOSHUA M PONCE
PRESENTED TO: PROF. JOSEPH DE LEON
Generalization

Human sexuality used to occupy a very prominent, if not central, place in conceptualizing
many psychological and developmental processes. With the arrival of new theories and
scientific findings, human sexuality’s “place in the sun” gradually diminished. However, an
unfortunate parallel process has taken place: human sexuality and the treatment of its
disorders seem to be gradually disappearing from psychiatrists’ clinical practice.

Sexual disorders are highly prevalent in the elderly, yet little is known about them. They
include sexual dysfunctions, paraphilic disorders, and gender dysphoria. Sexual dysfunctions
are characterized by diminished or absent sexual interests and imbalance in physiological
and psychological patterns. Paraphilias represent deviant or perverse sexual behavior, while
gender dysphoria is the condition of a person feeling that their gender identity is opposite to
their biological sex.

These problems can get aggravated by the process of aging or by the presence of multiple
stressors and chronic conditions.
Etiological Factors
Psychodynamics

 Individual causes of sexual desire disorders may include religious beliefs, obsessive-compulsive
personality, conflicts with gender identity or sexual preference, sexual phobias, fear of losing
control over sexual urges, secret sexual deviations, fear of pregnancy, inadequate grieving
following the death of a spouse, depression, and aging-related concerns. Psychological factors
may also be involved in arousal disorders.

Biological

 It is generally accepted that abnormal hormonal activity and biological (genetic) predisposition
interacting with social and family factors influence the development of these fantasies/sexual
acts. Although these behaviors may occur in normal sexual activity, when they become the
primary source of sexual satisfaction they may result in problems for the individual/others.
Etiological Factors
Family Dynamics

 There appears to be some evidence that paraphilias run in families and may be the result of
dysfunctional family interactions and social learning. Sexual dysfunctions are believed to be
influenced by what the individual has learned/not learned as a child within the family system
and by values and beliefs that may be based on myths and misconceptions.

“Many psychosocial factors affect desire, including discord in the relationship, psychosocial and
life stressors, major life changes, such as marriage, divorce, change in job, health problems in
family or children, or occupational stress. Finally, presence of other sexual disorders can affect
desire. Clearly, any of the sexual pain disorders are likely to be associated with low desire.
Discomfort with sexual orientation or gender identity disorder can all affect desire.”
Sexual Dysfunction(s)
 Sexual dysfunction refers to a problem occurring during any phase of the sexual response cycle
that prevents the individual or couple from experiencing satisfaction from the sexual activity.

 The sexual response cycle traditionally includes excitement, plateau, orgasm, and resolution.
Desire and arousal are both part of the excitement phase of the sexual response.

 Sexual dysfunction can affect any age, although it is more common in those over 40 because it
is often related to a decline in health associated with aging.

Causes

 Physical causes — Many physical and/or medical conditions can cause problems with sexual
function. These conditions include diabetes, heart and vascular (blood vessel) disease,
neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure,
and alcoholism and drug abuse. In addition, the side effects of some medications, including
some antidepressant drugs, can affect sexual function.
Sexual Dysfunction(s)
 Psychological causes — These include work-related stress and anxiety, concern about sexual
performance, marital or relationship problems, depression, feelings of guilt, concerns about
body image, and the effects of a past sexual trauma.

Types

Sexual dysfunction generally is classified into four categories:

 Desire disorders —lack of sexual desire or interest in sex

 Arousal disorders —inability to become physically aroused or excited during sexual activity
 Orgasm disorders —delay or absence of orgasm (climax)
 Pain disorders — pain during intercourse
Sexual Dysfunction(s)
Symptoms

In men:
 Inability to achieve or maintain an erection suitable for intercourse (erectile dysfunction)
 Absent or delayed ejaculation despite adequate sexual stimulation (retarded ejaculation)
 Inability to control the timing of ejaculation (early or premature ejaculation)

In women:
 Inability to achieve orgasm
 Inadequate vaginal lubrication before and during intercourse
 Inability to relax the vaginal muscles enough to allow intercourse

In men and women:

 Lack of interest in or desire for sex
 Inability to become aroused
 Pain with intercourse
Sexual Dysfunction(s)
Treatments

 Medication — When a medication is the cause of the dysfunction, a change in the medication
may help. Men and women with hormone deficiencies may benefit from hormone shots, pills, or
creams. For men, drugs, including sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®,
Staxyn®), and avanafil (Stendra®) may help improve sexual function by increasing blood flow to
the penis.

 Sex therapy — Sex therapists can be very helpful to couples experiencing a sexual problem that
cannot be addressed by their primary clinician. Therapists are often good marital counselors, as
well. For the couple who wants to begin enjoying their sexual relationship, it is well worth the time
and effort to work with a trained professional.

 Psychotherapy — Therapy with a trained counselor can help a person address sexual trauma
from the past, feelings of anxiety, fear, or guilt, and poor body image, all of which may have an
impact on current sexual function.
Sexual
Dysfunction(s)
Treatments

 Behavioral treatments — These involve various techniques,

including insights into harmful behaviors in the relationship,
or techniques such as self-stimulation for treatment of
problems with arousal and/or orgasm.

 Mechanical aids — Aids such as vacuum devices and

penile implants may help men with erectile dysfunction (the
inability to achieve or maintain an erection). A vacuum
device (Eros) is also approved for use in women, but can be
costly. Dilators may help women who experience narrowing
of the vagina.

 Education and communication — Education about sex and

sexual behaviors and responses may help an individual
overcome his or her anxieties about sexual function. Open
dialogue with your partner about your needs and concerns
also helps to overcome many barriers to a healthy sex life.
Paraphilic Disorders
 Paraphilic disorders are rarely part of the curriculum for psychiatry residents or fellows. As a result,
there are few psychiatrists who work with individuals who have paraphilic disorders.

 Paraphilias are emotional disorders defined as sexually arousing fantasies, urges, or behaviors
that are recurrent, intense, occur over a period of at least six months, and cause significant
distress or interfere with important areas of functioning.

 Paraphilic disorders are recurrent, intense, sexually arousing fantasies, urges, or behaviors that
are distressing or disabling and that involve inanimate objects, children or nonconsenting adults,
or suffering or humiliation of oneself or the partner with the potential to cause harm.

Causes

 A manifestation of arrested psychosexual development, with the paraphilic behaviors

defending the person's psyche against anxiety (defense mechanisms).
 A result of the sufferer associating something with sexual arousal and interests, or by having
unusual early life sexual experiences reinforced by having an orgasm.
Paraphilic Disorders
Causes

 Another form of obsessive-compulsive disorder or OCD.

 Temperament: a tendency to be overly inhibited or uncontrolled with emotions and behaviors.

 Early relationship formation: a lack of stable self-awareness, trouble managing emotions, and in
seeking help and comfort from others.

 Trauma repetition: People who are the victim of sexual or other forms of abuse, especially if it
occurs during childhood, may identify with the abuser such that they act out what was inflicted
on them by victimizing others in some way. They may also act out the trauma by somehow
harming themselves.

 Disrupted development of sexuality: The patterns of what brings one sexual pleasure tend to
form by adolescence. People raised in a household that is either excessively sexually permissive
or inhibited are at higher risk for developing a paraphilia.
Paraphilic Disorders
Types

According to the most current standard reference for mental disorders, the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), preceded by the DSM-IV and DSM-IV-
TR, there are a number of different types of paraphilias, each of which has a different focus of the
sufferer's sexual arousal:

 Voyeurism: watching an unsuspecting/non-consenting individual who is either nude, disrobing,

or engaging in sexual activity.
 Exhibitionism: exposing one’s own genitals to an unsuspecting person.
 Frotteurism: touching or rubbing against a non-consenting person.
 Sexual masochism: being humiliated, beaten, bound, or otherwise suffering.
 Sexual sadism: the physical or emotional suffering of another person.
 Pedophilia: sexual activity with a child that is prepubescent (usually 13 years old or younger).
 Transvestism: cross-dressing that is sexually arousing and interferes with functioning.
 Fetishism: sexual fascination with nonliving objects or highly specific body parts (partialism).
Examples of specific fetishisms include somnophilia.
 Autogynephilia is a subtype of transvestism that refers specifically to men who become aroused
by thinking or visualizing himself as a woman.
Paraphilic Disorders
Symptoms

 Tend to experience arousal by the stimulant to the exclusion or near exclusion of more common
sources of sexual interest, like an attractive person of similar age.

 The intensity of the sexual attraction can be overwhelming enough to cause distress.

 The unusual or forbidden nature of a paraphilia often causes symptoms of guilt and fear of
punishment.

 Preoccupation to the point of obsessiveness that may intrude on the person's attempts to think
about other things or engage in more conventional sexual activity with an age-appropriate
partner.

 May experience depression or anxiety that is temporarily relieved by engaging in paraphilic

behavior, thus leading to an addictive cycle.
Paraphilic Disorders
Treatments

 Medications:
 Antidepressants, such as lithium and various selective serotonin reuptake inhibitors (SSRIs).
 Long-acting gonadotropin-releasing hormones (ie, medical castration), such as leuprolide
acetate and triptorelin.
 Antiandrogens cyproterone acetate (CPA) and medroxyprogesterone acetate (MPA
[Amen, Depo-Provera) are the most commonly prescribed agents for the control of
repetitive deviant sexual behaviors

 Victim Identification: useful treatment intervention for individuals with exhibitionism, frotterism,
pedophilia, sexual sadism, and voyeurism. This type of treatment involves the therapist helping
the client to realize that the person they are doing the behavior to (i.e., exposing themselves,
exhibiting sadist-type behaviors) is a victim.
Paraphilic Disorders
Treatments

 Covert conditioning: is a behavioral method in which undesirable behavior becomes less

desirable and is eventually eliminated. In the case of paraphilias, the client is asked to imagine
feeling shame when friends or family members observe him engaging in the behavior
associated with the paraphilia.

 Orgasmic reconditioning: In orgasmic reconditioning the principles of learning are applied and
the client is first asked to identify a fantasy that involves the paraphilia in question. Next, they are
encouraged to engage in masturbation at home with specific instructions to become aroused
by the fantasy associated with their paraphilia, but to complete the masturbation exercise
(orgasm) while looking at an appropriate object (i.e., a picture of an adult partner). Finally, the
client is instructed not to incorporate the fantasy at all.

 Masturbatory Satiation: the client is encouraged to masturbate with the deviant fantasy in mind.
When the client reaches orgasm they must continue to masturbate to the deviant fantasy for
one hour. Since this activity does not end in reinforcing ejaculation, the client may eventually
loose interest in such fantasies
Paraphilic
Disorders
Treatments

 Aversive Therapies: include pairing arousal

to the deviant fantasy with either mild
electric shock or unpleasant smells (Plaud,
2007). If you have ever experienced food
poisoning, you will understand this
treatment intervention perfectly. Simply
imagine a food that has made you sick.
You are quite likely making a scrunched up
face as you read this.

 Group Therapy: may also be useful in the

treatment of paraphilias. The focus may be
on taking responsibility for actions, victim
impact and empathy, establishing family
support, building relationship and social
skills, and cognitive restructuring (Morin &
Levenson, 2008).
Gender Dysphoria
 Gender dysphoria (formerly known as gender identity disorder in the fourth version of the
Diagnostic and Statistical Manual of Mental Disorders, or DSM) is defined by strong, persistent
feelings of identification with another gender and discomfort with one's own assigned gender
and sex; in order to qualify for a diagnosis of gender dysphoria, these feelings must cause
significant distress or impairment.

 Desire to live in accordance with their gender identity and may dress and use mannerisms
associated with the gender with which they identify in order to achieve this goal.

 Suicidal ideation, suicide attempts, and substance-related disorders are relatively common
among those experiencing gender dysphoria.

Causes

 The causes of gender dysphoria are currently unknown, but genes, hormonal influences in the
womb, and environmental factors are all suspected to be involved.
 The onset of cross-gender interests and activities is usually between ages 2 and 4 years, and
many parents later report that their child has always had cross-gender interests.
Gender Dysphoria
Causes

Adult onset is typically in early to mid-adulthood. There are two common courses for the
development of gender dysphoria:

 The first, typically observed in late adolescence or adulthood, is a continuation of gender

dysphoria that had an onset in childhood or early adolescence.

 In the other course, the more overt signs of cross-gender identification appear later and more
gradually, with a clinical presentation in early to mid-adulthood.

Symptoms

Gender dysphoria looks different in different age groups. According to the DSM-5, health
professionals deciding whether to diagnose gender dysphoria in children, adolescents, and adults
should look for the presence of the following symptoms:

Children > Adolescents > Adulthood (see next slide)

Gender Dysphoria
Symptoms

In Children:
 An incongruence, present for six months or longer, between the child's experienced/expressed
gender and the gender they were assigned at birth
 A strong desire to be of the other gender (or another gender identity, such as non-binary) or an
insistence that one is another gender
 In boys (assigned gender), a strong preference for wearing or simulating female attire, and/or a
resistance to wearing traditional masculine clothing
 In girls (assigned gender), a strong preference for wearing typical masculine clothing, and/or a
resistance to wearing traditional feminine clothing
 A strong preference for cross-gender roles in make-believe or fantasy play
 A strong preference for the toys, games, or activities stereotypically used by the other gender
 A strong dislike of one's sexual anatomy

If at least six of the above symptoms are present, a diagnosis of gender dysphoria may be given if
it includes:
 Clinically significant distress or impairment in major areas of functioning, such as social
relationships, school, or home life
Gender Dysphoria
Symptoms

In Adolescents and Adults:

 An incongruence between the individual's experienced/expressed gender and primary sex
characteristics (sexual organs) and/or secondary sex characteristics (breasts, underarm hair),
lasting for at least six months
 A strong desire to be rid of one's primary and/or secondary sex characteristics
 A strong desire for the primary and/or secondary sex characteristics of the other gender
 A strong desire to be of the other gender or an alternative gender
 A strong desire to be treated as the other gender or an alternative gender
 A strong conviction that one has the typical feelings and reactions of the other gender or an
alternative gender

If at least two of the above symptoms are present, a diagnosis of gender dysphoria may be given if
it includes:
 Clinically significant distress or impairment in major areas of functioning, such as social
relationships, school, or home life
Gender Dysphoria
Treatments

For Children:

Depending on the results of this assessment, the options for children and young people with
suspected gender dysphoria can include:
 family therapy
 individual child
 psychotherapy
 parental support or counselling
 group work for young people and their parents regular reviews to monitor gender identity
development

 Hormone Therapy – GnRH analogues suppress the hormones produced by your child’s body.
They also suppress puberty and can help delay potentially distressing physical changes caused
by their body becoming even more like that of their biological sex, until they're old enough for
the treatment options discussed below.
Gender
Dysphoria
Treatments

For Adolescents & Adults:

 mental health support, such as counselling

 cross-sex hormone treatment (see below)
 speech and language therapy – to help alter your voice, to
sound more typical of your gender identity
 hair removal treatments, particularly facial hair
 peer support groups, to meet other people with gender dysphoria
 relatives' support groups, for your family

Hormone therapy for adults means taking the hormones of your

preferred gender:

 a trans man (female to male) will take testosterone (masculinising

hormones)
 a trans woman (male to female) will take oestrogen (feminising
hormones)

There'ssome uncertainty about the possible risks of long-term

masculinising and feminising hormone treatment.
References:

 https://my.clevelandclinic.org/health/diseases/9121-sexual-
dysfunction/management-and-treatment
 https://link.springer.com/chapter/10.1007/978-1-59745-252-6_16
 https://www.scribd.com/doc/97604062/Sexual-Disorder
 https://www.medicinenet.com/paraphilia/article.htm#paraphilia_fa
cts
 https://www.mentalhelp.net/sexual-disorders/paraphilias-causes-
and-treatments/
 https://www.psychologytoday.com/intl/conditions/gender-
dysphoria