Sexual Disorders

• Gender Incongruence of Adolescence or Adulthood
• Gender Incongruence of Childhood
• Gender Incongruence, Unspecified

Other Specified Conditions Related to Sexual Health

• Conditions Related to Sexual Health, Unspecified

Is persistent impairments of normal patterns of sexual interest or response that usually manifest as lack or loss of interest/enjoyment of sexual activities, the inability to experience or control orgasm, or a physiological barrier to successful sexual intercourse.

Individuals may avoid sexual opportunities, feel inadequate, or find it difficult to talk about it.

Criteria for a Diagnosis of Sexual Dysfunction Include:

• Inability to participate in a preferred sexual relationship.
• Presence of the sexual dysfunction on (almost) all occasions.
• Duration of at least 6 months.
• Significant stress or interpersonal difficulties.
• Not accounted for by a physical disorder, drug treatment (or use), or other mental or behavioral disorder.

Types of Sexual Dysfunctions

Sexual Desire Disorders

1. Hypoactive Sexual Desire Disorder
   • Most commonly diagnosed sexual dysfunction
   • More common in women than men
   • Little or no sexual interest or desire
   • Cause unclear
   • Not secondary to other sexual problems (e.g., dyspareunia or erectile failure)
2. Sexual Aversion Disorder
   • Strong negative feelings, fear, or anxiety due to the prospect of sexual interaction;
   • Of sufficient intensity to lead to active avoidance of sexual activity
3. Lack of Sexual Enjoyment
   • Lack of appropriate pleasure, despite normal sexual responses and achievement of orgasm
4. Excessive Sexual Desire
   • Presenting as a problem for individuals, partners, or carers (when sexual disinhibition occurs)
   • Referred to as nymphomania (women) or satyriasis (men)
   • Could be secondary to a mood disorder (e.g., mania), early stages of dementia, associated with learning disability, secondary to brain injury, or as a side-effect of some drugs

Sexual Arousal Disorders

Male Erectile Disorder or Erectile Dysfunction

• Persistent difficulty achieving or maintaining an erection sufficient to complete sexual activity
• May occur due to performance anxiety
• May have an organic cause

Female Sexual Arousal Disorder

• Persistent difficulties becoming sufficiently lubricated in response to sexual stimulation
• May have organic causes
• Usually has psychological causes, such as anger, resentment, or trauma

Orgasmic Disorders

Female Orgasmic Disorder

Could be anorgasmic or others.

Male Orgasmic Disorder

Includes:

• Delayed Ejaculation
• Retarded Ejaculation
• Ejaculatory Incompetence
• Premature Ejaculation

Sexual Pain Disorders

Dyspareunia

Occurs in both males and females.

Vaginismus

Paraphilias (DSM-IV)

Are disorders in which an individual is sexually aroused by inappropriate stimuli.

• Homosexuality was previously included, but this is no longer the case.
• High comorbidity with anxiety, mood, and substance abuse disorders.

DSM-IV Criteria:

• At least 6 months of recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving a particular inappropriate act or object.
• These fantasies, urges, or behaviors must cause clinically significant distress or impairment in social functioning.

ICD-10 Criteria:

Has less strict and less detailed criteria, referring to the particular object or act as being the most important source of sexual arousal or essential for satisfactory sexual response.

Classification of Disorders of Sexual Preference - ICD 10

• Fetishism
• Fetishistic Transvestism
• Exhibitionism
• Voyeurism
• Paedophilia
• Sadomasochism
• Other Disorders of Sexual Preference
• Multiple Disorders of Sexual Preference

Paraphilias

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Paraphilias

Voyeurism

• Risk associated with "peeping" is necessary for sexual arousal

Exhibitionism

• Element of thrill and risk is necessary for sexual arousal

Relation Between Sadism and Rape

• Some rapists are sadists, but most do not show paraphilic patterns of arousal
• Rapists show sexual arousal to violent sexual and non-sexual material

Pedophilia

• Pedophiles: Individuals with a sexual attraction to young children
• Incest: Sexual attraction to one's own children
• Both may involve male and/or female children or very young adolescents
• Pedophilia is rare in females
• Incestuous males may be aroused to adult women; not true for pedophiles
• Most rationalize the behavior and engage in other moral compensatory behavior

Causes of Pedophilia

• Sexual and social problems and deficits
• Patterns of inappropriate arousal and fantasy may be learned early in life
• The role of high sex drive, coupled with suppression of urges

Psychophysiological Assessment of Pedophilia

• Assess extent of deviant patterns of sexual arousal
• Assess extent of desired sexual arousal to adult content
• Assess social skills and the ability to form relationships

TREATMENT

Psychosocial Interventions

• Most are behavioral and target deviant and inappropriate sexual associations
• Covert Sensitization – Imaginal procedure involving aversive consequences
• Orgasmic Reconditioning – Associate masturbation with appropriate stimuli
• Family/Marital Therapy – Address interpersonal problems
• Coping and Relapse Prevention – Teaches self-control and coping with risk

Medications: The Equivalent of Chemical Castration

• Often used for dangerous sexual offenders

Types of Available Medications

• Cyproterone acetate – Anti-androgen, reduces testosterone, sexual urges, and fantasy
• Medroxyprogesterone acetate – Depo-Provera, also reduces testosterone
• Triptorelin – A newer and more effective drug that inhibits gonadotropin secretion

Efficacy of Medication Treatments

• Drugs work to greatly reduce sexual desire, fantasy, arousal
• Relapse rates are high with medication discontinuation

Prognosis

• About 70% to 100% of cases show improvement
• Poorest outcomes are for rapists and persons with multiple paraphilias
• Most pedophilias run a chronic course and relapse rates are high

• Transexualism
• Characterized by the desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with one’s anatomical sex.
• Gender identity develops between 18 months and 3 years of age.
• Feels trapped in the body of the wrong sex. Most report that their gender dysphoria was present from early childhood. Karyotype and phenotypic development are normal.
• Transsexual identity should have been present for at least 2 years and must not be a symptom of another mental disorder, such as schizophrenia, or associated with any intersex, genetic, or chromosomal abnormality.
• TF to FTM ratio is 3–4:1

Differential Diagnosis

• Transvestism
• Fetishistic Transvestism
• Dual Role Transvestism
• Dysmorphobia
• Intersexed Condition
• Third Sex
• Schizophrenia

Treatment

• Psychological - Supervision of the transition, liaison with the primary care and surgical teams, and psychological support during the inevitable difficulties.
• Real-Life Test - At least 1 year before consideration of surgery
• Hormones
• Sex-Reassignment Surgery
• 75% report satisfaction with the new identity
• Female-to-male conversions adjust better than male-to-female