Sexual Dysfunctions,

Paraphilic Disorders,
and Gender Dysphoria

Confesor, Pamela
Gregorio, Ria Joelle
Paglinawan, Jeremiel
Torregosa, April Athena
DIAGNOSTIC
CRITERIA OF
PARAPHILIC
DISORDERS
Paraphilic Disorders
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
Voyeuristic Disorder
Voyeurism involves becoming sexually
aroused by watching an unsuspecting
person who is disrobing, naked, or
engaged in sexual activity.

Voyeuristic disorder is very uncommon

among women in clinical settings,
whereas the ratio in men to women for
single sexually arousing voyeuristic
acts is less extreme and may be 2:1–
3:1.
Diagnostic Criteria
Voyeuristic Disorder

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.

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.

The individual experiencing the arousal and/or acting on the

urges is at least 18 years of age.
Exhibitionistic
Disorder
Individuals with exhibitionism
experience recurrent, intense sexual
arousal from the act of exposing their
genitals to an unsuspecting person.
(e.g., exposing his genitals to riders on
a train)
Diagnostic Criteria
Exhibitionistic Disorder

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.

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.
Frotteuristic Disorder
Individuals with frotteurism experience
recurrent intense sexual arousal from
the act of touching or rubbing against a
nonconsenting person.
Diagnostic Criteria
Frotteuristic Disorder

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.

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.
Sexual Masochism
Disorder
Individuals with sexual masochism
experience recurrent, intense sexual
arousal from the act of being
humiliated, beaten, bound, or otherwise
made to suffer.
Diagnostic Criteria
Sexual Masochism Disorder

Over a period of at least 6 months, recurrent and intense sexual

arousal from the act of being humiliated, beaten, bound, or
otherwise made to suffer, as manifested by fantasies, urges, or
behaviors.

The fantasies, sexual urges, or behaviors cause clinically

significant distress or impairment in social, occupational, or
other important areas of functioning.
Sexual Sadism
Disorder
Individuals with sexual sadism
experience recurrent, intense sexual
arousal from the physical or
psychological suffering of another
person.
Diagnostic Criteria
Sexual Sadism Disorder

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.

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.
Pedophilic Disorder
Individuals with pedophilia experience
recurrent, intense, sexually arousing
fantasies or sexual urges involving
sexual activity with a prepubescent
child or children.
Diagnostic Criteria
Pedophilic Disorder

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).

The individual has acted on these sexual urges, or the sexual

urges or fantasies cause marked distress or interpersonal
difficulty.

The individual is at least age 16 years and at least 5 years older

than the child or children in Criterion A.
Fetishistic Disorder
is characterized by a distressing and
persistent pattern of sexual arousal
involving the use of nonliving objects or
specific, nongenital body parts.
Diagnostic Criteria
Fetishistic Disorder

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.

The fantasies, sexual urges, or behaviors cause clinically significant

distress or impairment in social, occupational, or other important
areas of functioning.

The fetish objects are not limited to articles of clothing used in

cross-dressing (as in transvestic disorder) or devices specifically
designed for the purpose of tactile genital stimulation (e.g.,
vibrator).
Transvestic Disorder
Individuals with transvestism
experience recurrent and intense
sexual arousal from cross-dressing.
Diagnostic Criteria
Transvestic Disorder

Over a period of at least 6 months, recurrent and intense sexual

arousal from cross-dressing, as manifested by fantasies, urges,
or behaviors.

The fantasies, sexual urges, or behaviors cause clinically

significant distress or impairment in social, occupational, or
other important areas of functioning.
CAUSES OF SEXUAL
DYSFUNCTION
CAUSES OF
SEXUAL
DYSFUNCTION
BIOLOGICAL CONTRIBUTIONS
Neurological diseases that affect
the nervous system may directly
interfere with sexual functioning.
By reducing sensitivity in the genital area

Diabetes Vascular Disease

Relevant
vascular
problems

venous leakage
arterial insufficiency
which makes it difficult blood flows out too
for blood to reach the quickly for an erection to
penis be maintained
Chronic Illness can also indirectly affect sexual
functioning

it is not uncommon for individuals

who have had heart attacks to be
wary of the physical exercise
involced in sexual activity

They often become unable to

achieve arousal
Prescription Alcohol Nicotine
Medication
low - moderate levels : associated with impaired
"anti-hypertensive reduces social inhibition sexual performance
medications" Chronic alcohol abuse smoking was associated
SSRI antidepressant may cause permanent with increased erectile
medication neurological damage dysfunction
antianxiety drugs fertility problems in both
men and women
CAUSES OF
SEXUAL
DYSFUNCTION
PSYCHOLOGICAL
CONTRIBUTIONS
Most sex researchers and In certain circumstances, anxiety
therapists thought the principal increases sexual arousal.
cause of sexual dysfunctions was
anxiety
Sarrel and Masseters They had been able to achieve
erections and repeatedly engage in
(1982): intercourse despite being constatly
threatened with knives and other
described the ability of weapons if they failed
men to perform sexually
under the threat of
physical harm They experience extreme levels of
anxiety yet they reported that their
sexual performance was not impaired.
If anxiety does not
necessarily decrease sexual
arousal and performance,
what does?

A partial andwer:

DISTRACTION
Sexually functional males
demonstrated significantly less
arousal based on penile strain gause
measurements by the nattative than
when they are not distracted.

Males with erectile dysfunction in

whom physical disease processes had
been ruled out reacted somewhat
differently from functional men to
both shock threat and distraction
condition.
Performance anxiety

arousal cognitive negative

processes affect
Possibility
of having
sexual dysfunctional normal functioning
relations — tend to expect the worst — focus their attention on
and find the situation to be the erotic cues and do not
relatively negative and become distracted.
unpleasant.

— avoid becoming aware of — when they become

any sexual cues aroused, they focus even
more strongly on the sexual
— amay distract themselves and erotic cues, allowing
with negative throughts themselves to become
increasingly aroused.
Normally functioning individuals : Individuals with sexual problems:

increased arousal during decreased arousal during

"performance demand" perfomance demand
conditions experience negative affect
experience positive affect distracted by nonsexual stimuli
not distracted by nonsexual do not have accurate sense of
stimuli how aroused they are
have a good idea of how
aroused they are
CAUSES OF
SEXUAL
DYSFUNCTION
SOCIAL AND CULTURAL
CONTRIBUTIONS
Many people learn early that sexuality
can be negative and somewhat
threatening, and the responses they
develop reflect this belief.
Erotophobia
presumably learned early in childhood
from families, religious authorities, or
others, seems to predict sexual
difficulties later in life.
Both men and women may experience
specific negative or traumatic events
after a period of relatively well-
adjusted sexuality.

— sudden failure to become aroused

— actual sexual trauma such as rape, as
well as early sexual abuse.
 substantial impact of early
Laumann and traumatic sexual events on later
sexual functioning, particularly in
colleagues (1999) women

if women were sexually victimized

by an adult before puberty or
were forced to have sexual
contact of some kind...

They were approximately twice as

likely to have orgasmic
dysfunction as women who had
not been touch before puberty or
forced to have sex at any time
Traumatic sexual acts of all kinds
have long-lasting effects on
subsequent sexual functioning

Such stressful events may initiate negative affect,

which individuals experience a loss of control over
their sexual response cycle, throwing them out into
the kind of dysfunctional pattern.
Marked detoriation in close
interpersonal relationship

It is difficult to have a satisfactory sexual relationship

in the context of growing dislike for a partner.

Occasionally, the partner may no longer seem

physically attractive.

It is also important to feel attractive yourself

Koch, Mansfield, Thurau, and the more a woman perceived
Carey (2005) herself as less attractive than
before, the more likely she was to
have sexual problems

Kelly, Strassberg, and Kircher Anorgasmic women, in addition to

(1990) displaying more negative attitudes
toward masturbation, greater sex
guilt, and greater endorsement of
sex myths

Reported discomfort in telling

partners what sexual aactivities
might increase their arousal or
lead to orgasm, such as direct
clitoral stimulation
Script Theory
— We all operate by following "scripts" that
reflect social and cultural expectations and
guide our behavior.
Script Theory
A person who learns that sexuality is
potentially dangerous, dirty, or
forbidden is more vulnerable to
developing sexual dysfunction later in
life.

This pattern is evident in cultures

with restrictive attitudes toward
sex.
Script Theory
A person who learns that sexuality is
potentially dangerous, dirty, or
forbidden is more vulnerable to
developing sexual dysfunction later in
life.

This pattern is evident in cultures

with restrictive attitudes toward
sex.
Script Theory
77% of a large number of male patients in sexuality in
India reported difficulties with premature ejaculation.

71% of male patients complained of being extremely

concerned about nocturnal emissions ("wet dreams")
associated with erotic dreams.

Strong culturally helf belief in India that loss of

semen causes depletion of physical and mental
energy.
Interaction of
Psychological and
Physical Factors
Socially transmitted negative attitudes about
sex may interact with a person's relationship
difficulties and predispositions to develop
performance anxiety and ultimately lead to
sexual dysfuntion
Psychological
point-of-view
It is not clear why some individuals develop one
dysfunction and not another, although it is
common for several dysfunctions to occur in the
same patients.
 Possibly, an individual's specific
biological predispositions interact
with psychological factors to produce a
specific sexual dysfunction.
CAUSES OF
PARAPHILIC
DISORDERS
Deviant patterns of sexual arousal
often occur in the context of
other sexual and social problems

An inability to develop adequate social relations with the

appropriate people for sexual relationships seems to be
associated with a developing of inappropriate sexual
outlets

presence of disordered relationships during

childhood and adolescence with resulting
defitcits in healthy sexual developmet.
Nature of the person's early
sexual fantasies.
— demonstrated that sexual arousal could
become associated with a neutral object
Clinical or operant-
conditioning paradigm

Behavior repeatedly pleasurable

sex-arousal to a reinforced consequence
specific object or orgasm
activity
Psychopathologists are also becoming
interested in the phenomenon of weak
inhibitory control across these
paraphilic disorders

— may indicate a weak

biologically based behavioral
inhibition system (BIS) in the
brain that might repress
serotonergic function.
CAUSES OF GENDER
DYSPHORIA
Sexual
Orientation
slightly higher levels of
testosterone or estrogen at certain
critical periods might masculinize
a female fetus or feminize a male
fetus.
Congenital Adrenal
Hyperplasia (CAH)
Brains of chromosomal females are flooded with
male hormones (androgens)
-> produce mostly masculine external genitalia,
altough internal organs remain female.

CAH girls were masculine in their behavior, but

there were no differences in gender identity.
18 months and 3 years of age
— Gender identity firms up

— Iis relatively fixed after that.

 Gender nonconformity
behavior or gender expression by an individual that
does not match masculine or feminine gender norm

boys behave in girls behave in

feminine ways masculine ways
Most boys spontaneously display "feminine" interests and
behaviors

typically discouraged by most families and these

behaviors usually cease.

Boys who consistently display these behaviors are not

discouraged, however, and are sometimes encouraged.

Other Factors:
excessive attention and physical contact on the part of
the mother
lack of male playmates during the early years of
socialization
Biological Factors Exposure to higher levels of fetal
testosterone was associated with
more masculine play behavior in
both boys and girls during childhood.

Few seem to develop gender

incongruence

Most likely outcome is the

development of homosexual
preferences
Psychosocial Treatment

Sensate focus and non-demand pleasuring

- In this exercise, couples are instructed to refrain from intercourse or genital

caressing and simply to explore and enjoy each other’s body through touching, kissing,
hugging, massaging, or similar kinds of behavior. In the first phase, non-genital pleasuring,
breasts and genitals are excluded from the exercises.
After successfully accomplishing this phase, the couple moves to genital pleasuring
but with a ban on orgasm and intercourse and clear instructions to the man that achieving an
erection is not the goal. At this point, arousal should be reestablished and the
couple should be ready to attempt intercourse
Psychosocial Treatment
For premature ejaculation

Squeeze

penis is stimulated, usually by the partner, to nearly full erection. At this point,
the partner firmly squeezes the penis near the top where the head
of the penis joins the shaft, which quickly reduces arousal. These
steps are repeated until (for heterosexual partners) eventually the penis
is briefly inserted in the vagina without thrusting. If arousal occurs too quickly,
the penis is withdrawn and the squeeze technique is
employed again. In this way, the man develops a sense of control over
arousal and ejaculation
Psychosocial Treatment
For lifelong female orgasmic disorder

Explicit training in masturbatory procedures

Psychosocial Treatment
Psychosocial Treatment
Medical Treatment
For Erectile Dysfunction in Men

1. Oral Medication (Viagra paired with CBT)

Medical Treatment
For Erectile Dysfunction in Men

2. Injection of vasoactive substances directly into the penis

(Papaverine or Prostaglandin)
these drugs dilate the blood vessels, allowing blood
to flow to the penis and thereby producing an erection
within 15 minutes that can last from 1 to 4 hours
Medical Treatment
For Erectile Dysfunction in Men

3. Surgery (Insertion of penile prostheses or implants)

implanting a semi-rigid silicone rod that can be bent
by the male into correct position for intercourse
and maneuvered out of the way at other times. In a
more popular procedure, the male squeezes a small
pump that is surgically implanted into the scrotum,
forcing fluid into an inflatable cylinder and thus
producing an erection.
Medical Treatment
For Erectile Dysfunction in Men

4. Vacuum device therapy

works by creating a vacuum in a cylinder placed over the
penis. vacuum draws blood into the penis, which is then
trapped by a specially designed ring placed around the base
of the penis
Psychological Treatment
For Increasing Unwanted Arousal

Covert Sensitization
Drug Treatment
For Increasing Unwanted Arousal

Cyproterone Acetate (antiandrogen)

This “chemical castration” drug
eliminates sexual
desire and fantasy by reducing
testosterone levels dramatically, but
fantasies and arousal return as soon
as the drug is removed
Drug Treatment
For Increasing Unwanted Arousal

Medroxyprogesterone
A hormonal agent that reduces
testosterone. These drugs may be
useful for dangerous sexual offenders
who do not respond to alternative
treatments or to temporarily suppress
sexual arousal in patients who require
it, but it is not always successful
Drug Treatment
For Increasing Unwanted Arousal

Triptorelin
This drug inhibits gonadotropin
secretion in men
Sex Reassignment Surgery

In transwomen, hormones are administered In transmen, an artificial penis is typically

to promote gynecomastia (the growth of constructed through plastic surgery, using
breasts) and the development of other sections of skin and muscle from
secondary sex characteristics. Facial hair is elsewhere in the body, such as the thigh.
typically removed through electrolysis. If Breasts are surgically removed. Genital
the individual is satisfied with the events of surgery is more difficult and complex in
the trial period, the genitals are removed natal females
and a vagina is constructed.
Treatment of Gender Nonconformity in Children
The following are treatment guidelines developed by the American Psychiatric
Association and the American Psychological Association

First Approach, work with the child and caregivers to Second approach, “watchful waiting” by letting
lessen gender dysphoria and decrease cross-gender expressed gender unfold naturally. This goal
behaviors and identification on the assumption that these requires strong support from caregivers and the
behaviors are unlikely to persist anyway and the negative community because of the potential social and
consequences of social rejection could be avoided and that interpersonal risks and lack of integration with peer
avoiding later intrusive surgery groups
would be desirable

Third approach, advocates actively alarming and encouraging cross-

gender identification, but critics point out that gender nonconformity
usually does not persist and that taking this course would increase
the likelihood of persistence. There is very little hard scientifically
information on which course would be the most beneficial for a
given child
Treatment of Gender Nonconformity in Children

In pre-pubescent children, medical intervention that blocks puberty

psychoeducation and therapy to help allows the adolescent time to continue
clarify gender identity and navigate exploring gender identity issues without
the complex social issues associated the added of stress of beginning puberty
with cross-gender identification in a gender that is inconsistent with their
identity
Treatment of Disorders of Sex Development
(Intersexuality)
Surgery and hormonal replacement
therapy allows the adolescent time to
continue exploring gender identity issues
without the added of stress of beginning
puberty in a gender that is inconsistent
with their identity