W1.1
CHAPTER 12 (KRING & JOHNSON) – SEXUAL DISORDERS
SEXUAL DISORDERS
Penile plethysmograph/vaginal plethysmograph: Measures biological arousal or blood flow to
the genitalia
Sexual interest: Sexual desire, often associated with sexually arousing fantasies or thoughts –
Interest and subjective arousal often co-occur for women, and women’s sexual interest often
follows their biological arousal
Subjective arousal: Self-perceptions of sexual excitement
Biological arousal: Changes in blood flow to genitalia, which can be measured by penile or
vaginal plethysmography
Orgasm: Ejaculation in men; contraction of the outer walls of the vagina in women
Resolution: Post-orgasm phase; for men further erection is not possible during a refractory
period
Gender identity: A person’s inherent sense of being male or female, which is distinct from
sexual orientation
↓
Gender dysphoria: Diagnosis for people who experience a strong and persistent identification
that differs from the sex they were assigned at birth – Reasons why gender dysphoria should
not be included in the DSM:
- Cross-gender behaviour is universal
- The existence of this diagnosis implicitly contradicts the need for treatments to change
a person’s body to suit the person’s gender identity
- Diagnosing gender nonconformity might foster stigma
Many people with one form of sexual dysfunction will report a second form of sexual
dysfunction – Vicious cycle
CLINICAL DESCRIPTIONS (SEXUAL DISORDERS)
Many people with one form of sexual dysfunction will report a second form of sexual
dysfunction – Vicious cycle
Although more than a quarter of people report at least brief symptoms of sexual dysfunction,
less than 5% report that these symptoms persist for 6 months and cause distress
,Sexual interest, desire and arousal
Female sexual interest/arousal disorder: Persistent deficits in sexual interest, biological
arousal or subjective arousal
- Diminished, absent or reduced frequency of at least three of the following: interest in
sexual activity; erotic thoughts or fantasies; initiation of sexual activity and
responsiveness to partner’s attempts to initiate; sexual excitement during 75% of
sexual encounters; sexual interest/arousal elicited by any internal or external erotic
cues; genital or non-genital sensations during 75% of sexual encounters
Male hypoactive sexual desire disorder: Deficient or absent sexual fantasies and urges
Erectile disorder: Failure to maintain an erection through completion of the sexual activity
- On at least 75% of sexual occasions: inability to attain an erection, inability to
maintain an erection, or marked decrease in erectile rigidity that interferes with
penetration or pleasure
- The problem is physical arousal
- The prevalence of erectile disorder increases with age
Orgasmic disorder
Female orgasmic disorder: The persistent absence or reduced intensity of orgasm after sexual
excitement
- Women differ in their thresholds for orgasms
- On at least 75% of sexual occasions: marked delay, infrequency or absence of orgasm,
or markedly reduced intensity of orgasmic sensation
- Women become more likely to have orgasms as they age and are more likely to have
orgasms in close relationships than they are in casual, short-term relationships
- Many women with orgasmic disorder achieve sexual arousal and enjoy sexual contact,
but have difficulty reaching orgasm
Premature (early) ejaculation: Ejaculation that occurs too quickly
- ‘Premature’ = less than 1 minute after the penis is inserted
- At least on 75% of sexual occasions
Delayed ejaculation disorder: Marked delay, infrequency or absence of orgasm on at least
75% of sexual occasions
Sexual pain
Genito-pelvic pain/penetration disorder: Persistent or recurrent pain during intercourse
- Focus on women, very few men seek treatment for recurrent pain during sex
- Vaginismus: Involuntary muscle spasms of the outer third of the vagina to a degree
that makes intercourse impossible
- Persistent/recurrent difficulties with at least one of the following: inability to have
vaginal penetration during intercourse; marked vulvar, vaginal, or pelvic pain during
vaginal penetration or intercourse attempts; marked fear about pain or penetration;
marked tensing of the pelvic floor muscles during attempted vaginal penetration
,ETIOLOGY OF SEXUAL DISORDERS
Biological explanations:
- Diseases (such as diabetes, multiple sclerosis and spinal cord injury), heavy alcohol
use before sex, chronic alcohol use and heavy cigarette smoking can cause sexual
dysfunction
- Sexual dysfunctions among men can be exacerbated by low levels of testosterone or
by the high levels induced by chronic use of steroids or testosterone supplements
- Certain medications, such as SSRIs, have effects on sexual function, including
decreased arousal and higher rates of orgasmic disorders
- Erectile disorder symptoms are often related to vascular disorder, which restricts blood
flow into the veins of the penis
- Neurologically based super-sensitivity to pain could contribute to genito-pelvic
pain/penetration disorder, and low oestradiol or testosterone can contribute to low
sexual desire
Psychosocial influences:
- Some sexual dysfunctions can be traced to rape, sexual abuse, or an absence of
positive sexual experiences – Childhood sexual abuse is associated with diminished
arousal and desire, higher rates of genital pain, and, among men, with double the rate
of premature ejaculation
- Lack of opportunities to learn about one’s sexuality and to develop sexual skills
- Relationship problems often interfere with sexual arousal and pleasure – People who
are angry with their partners are less likely to want sex, and poor communication
around sex can contribute to sexual dysfunction, particularly for women
- Depression and anxiety increase the risk of sexual dysfunctions – Particularly
comorbid with sexual pain, lack of sexual desire or arousal and female orgasmic
disorder
- Low general physiological arousal can interfere with sexual arousal – Experiment:
Exercise facilitated sexual arousal
- Negative cognitions can interfere with sexual functioning – Negative thoughts about
weight or appearance impinge on sexual enjoyment for many women
- Self-blame – Experiment: The men who were given an internal explanation reported
less subjective arousal and also showed less physiological arousal during the second
film than those given an external explanation
- Negative views of sexuality from social and cultural surroundings
TREATMENT OF SEXUAL DISORDERS
Psychoeducation: Good information about how common sexual dysfunction is, and about the
sources of these types of issues – Allows therapists to normalise the concern, reduce anxiety,
model effective communication about sexuality and eliminate blame
Couples therapy: Includes communication skill training, planning romantic events together
and encouraging partners to communicate their sexual likes and dislikes to each other
Cognitive interventions: Used to challenge the self-demanding, perfectionistic thoughts that
cause problems for many people with sexual dysfunctions
, Sensate focus: A type of therapy in which the therapist instructs partners to choose a time
when both partners feel a sense of warmth and compatibility and to undress and give each
other pleasure by touching each other’s bodies – The one being touched is not required to feel
a sexual response and is responsible for immediately telling the partner if something becomes
uncomfortable – Promotes contact (Masters & Johnson)
Treatment for specific disorders:
- Female sexual interest/arousal disorder – Flibanserin (Addyi) can be prescribed for
premenopausal women with low sexual desire – Limited efficacy compared to a
placebo and high rates of side effects
- Female orgasmic disorder – Directed masturbation: The woman is instructed to
examine her genitals and to identify various areas with the aid of diagrams, after
which she is instructed to touch her genitals and to find areas that produce pleasure
using erotic fantasies and/or a vibrator
- Genito-pelvic pain/ penetration disorder – Training in relaxation and practicing
inserting fingers or dilators into one’s vagina
- Premature ejaculation:
- SSRI antidepressants
- Squeeze technique: A partner is trained to squeeze the penis in the area where
the head and shaft meet to rapidly reduce arousal – During insertion, the penis
is withdrawn and the squeeze is repeated as needed
- Withdrawing the penis as needed during intercourse to reduce arousal
- Erectile disorder – Phosphodiesterase type 5 (PDE-5) inhibitors can be prescribed,
such as sildenafil (Viagra), tadafil (Cialis), vardenafil (Levitra), or avanafil (Stendra) –
Relax smooth muscles and thus allow blood to flow into the penis, creating an erection
during sexual stimulation but not in its absence
PARAPHILIC DISORDERS
Paraphilic disorder: Recurrent sexual attraction to unusual objects or activities, lasting at least
6 months – Distress, impairment, and engagement of nonconsenting others are important
boundaries between normative and problematic sexual behaviour – Some of the paraphilias do
not involve nonconsenting others
Paraphilic disorders are more common among heterosexual males
CLINICAL DESCRIPTIONS (PARAPHILIC DISORDERS)
CHAPTER 12 (KRING & JOHNSON) – SEXUAL DISORDERS
SEXUAL DISORDERS
Penile plethysmograph/vaginal plethysmograph: Measures biological arousal or blood flow to
the genitalia
Sexual interest: Sexual desire, often associated with sexually arousing fantasies or thoughts –
Interest and subjective arousal often co-occur for women, and women’s sexual interest often
follows their biological arousal
Subjective arousal: Self-perceptions of sexual excitement
Biological arousal: Changes in blood flow to genitalia, which can be measured by penile or
vaginal plethysmography
Orgasm: Ejaculation in men; contraction of the outer walls of the vagina in women
Resolution: Post-orgasm phase; for men further erection is not possible during a refractory
period
Gender identity: A person’s inherent sense of being male or female, which is distinct from
sexual orientation
↓
Gender dysphoria: Diagnosis for people who experience a strong and persistent identification
that differs from the sex they were assigned at birth – Reasons why gender dysphoria should
not be included in the DSM:
- Cross-gender behaviour is universal
- The existence of this diagnosis implicitly contradicts the need for treatments to change
a person’s body to suit the person’s gender identity
- Diagnosing gender nonconformity might foster stigma
Many people with one form of sexual dysfunction will report a second form of sexual
dysfunction – Vicious cycle
CLINICAL DESCRIPTIONS (SEXUAL DISORDERS)
Many people with one form of sexual dysfunction will report a second form of sexual
dysfunction – Vicious cycle
Although more than a quarter of people report at least brief symptoms of sexual dysfunction,
less than 5% report that these symptoms persist for 6 months and cause distress
,Sexual interest, desire and arousal
Female sexual interest/arousal disorder: Persistent deficits in sexual interest, biological
arousal or subjective arousal
- Diminished, absent or reduced frequency of at least three of the following: interest in
sexual activity; erotic thoughts or fantasies; initiation of sexual activity and
responsiveness to partner’s attempts to initiate; sexual excitement during 75% of
sexual encounters; sexual interest/arousal elicited by any internal or external erotic
cues; genital or non-genital sensations during 75% of sexual encounters
Male hypoactive sexual desire disorder: Deficient or absent sexual fantasies and urges
Erectile disorder: Failure to maintain an erection through completion of the sexual activity
- On at least 75% of sexual occasions: inability to attain an erection, inability to
maintain an erection, or marked decrease in erectile rigidity that interferes with
penetration or pleasure
- The problem is physical arousal
- The prevalence of erectile disorder increases with age
Orgasmic disorder
Female orgasmic disorder: The persistent absence or reduced intensity of orgasm after sexual
excitement
- Women differ in their thresholds for orgasms
- On at least 75% of sexual occasions: marked delay, infrequency or absence of orgasm,
or markedly reduced intensity of orgasmic sensation
- Women become more likely to have orgasms as they age and are more likely to have
orgasms in close relationships than they are in casual, short-term relationships
- Many women with orgasmic disorder achieve sexual arousal and enjoy sexual contact,
but have difficulty reaching orgasm
Premature (early) ejaculation: Ejaculation that occurs too quickly
- ‘Premature’ = less than 1 minute after the penis is inserted
- At least on 75% of sexual occasions
Delayed ejaculation disorder: Marked delay, infrequency or absence of orgasm on at least
75% of sexual occasions
Sexual pain
Genito-pelvic pain/penetration disorder: Persistent or recurrent pain during intercourse
- Focus on women, very few men seek treatment for recurrent pain during sex
- Vaginismus: Involuntary muscle spasms of the outer third of the vagina to a degree
that makes intercourse impossible
- Persistent/recurrent difficulties with at least one of the following: inability to have
vaginal penetration during intercourse; marked vulvar, vaginal, or pelvic pain during
vaginal penetration or intercourse attempts; marked fear about pain or penetration;
marked tensing of the pelvic floor muscles during attempted vaginal penetration
,ETIOLOGY OF SEXUAL DISORDERS
Biological explanations:
- Diseases (such as diabetes, multiple sclerosis and spinal cord injury), heavy alcohol
use before sex, chronic alcohol use and heavy cigarette smoking can cause sexual
dysfunction
- Sexual dysfunctions among men can be exacerbated by low levels of testosterone or
by the high levels induced by chronic use of steroids or testosterone supplements
- Certain medications, such as SSRIs, have effects on sexual function, including
decreased arousal and higher rates of orgasmic disorders
- Erectile disorder symptoms are often related to vascular disorder, which restricts blood
flow into the veins of the penis
- Neurologically based super-sensitivity to pain could contribute to genito-pelvic
pain/penetration disorder, and low oestradiol or testosterone can contribute to low
sexual desire
Psychosocial influences:
- Some sexual dysfunctions can be traced to rape, sexual abuse, or an absence of
positive sexual experiences – Childhood sexual abuse is associated with diminished
arousal and desire, higher rates of genital pain, and, among men, with double the rate
of premature ejaculation
- Lack of opportunities to learn about one’s sexuality and to develop sexual skills
- Relationship problems often interfere with sexual arousal and pleasure – People who
are angry with their partners are less likely to want sex, and poor communication
around sex can contribute to sexual dysfunction, particularly for women
- Depression and anxiety increase the risk of sexual dysfunctions – Particularly
comorbid with sexual pain, lack of sexual desire or arousal and female orgasmic
disorder
- Low general physiological arousal can interfere with sexual arousal – Experiment:
Exercise facilitated sexual arousal
- Negative cognitions can interfere with sexual functioning – Negative thoughts about
weight or appearance impinge on sexual enjoyment for many women
- Self-blame – Experiment: The men who were given an internal explanation reported
less subjective arousal and also showed less physiological arousal during the second
film than those given an external explanation
- Negative views of sexuality from social and cultural surroundings
TREATMENT OF SEXUAL DISORDERS
Psychoeducation: Good information about how common sexual dysfunction is, and about the
sources of these types of issues – Allows therapists to normalise the concern, reduce anxiety,
model effective communication about sexuality and eliminate blame
Couples therapy: Includes communication skill training, planning romantic events together
and encouraging partners to communicate their sexual likes and dislikes to each other
Cognitive interventions: Used to challenge the self-demanding, perfectionistic thoughts that
cause problems for many people with sexual dysfunctions
, Sensate focus: A type of therapy in which the therapist instructs partners to choose a time
when both partners feel a sense of warmth and compatibility and to undress and give each
other pleasure by touching each other’s bodies – The one being touched is not required to feel
a sexual response and is responsible for immediately telling the partner if something becomes
uncomfortable – Promotes contact (Masters & Johnson)
Treatment for specific disorders:
- Female sexual interest/arousal disorder – Flibanserin (Addyi) can be prescribed for
premenopausal women with low sexual desire – Limited efficacy compared to a
placebo and high rates of side effects
- Female orgasmic disorder – Directed masturbation: The woman is instructed to
examine her genitals and to identify various areas with the aid of diagrams, after
which she is instructed to touch her genitals and to find areas that produce pleasure
using erotic fantasies and/or a vibrator
- Genito-pelvic pain/ penetration disorder – Training in relaxation and practicing
inserting fingers or dilators into one’s vagina
- Premature ejaculation:
- SSRI antidepressants
- Squeeze technique: A partner is trained to squeeze the penis in the area where
the head and shaft meet to rapidly reduce arousal – During insertion, the penis
is withdrawn and the squeeze is repeated as needed
- Withdrawing the penis as needed during intercourse to reduce arousal
- Erectile disorder – Phosphodiesterase type 5 (PDE-5) inhibitors can be prescribed,
such as sildenafil (Viagra), tadafil (Cialis), vardenafil (Levitra), or avanafil (Stendra) –
Relax smooth muscles and thus allow blood to flow into the penis, creating an erection
during sexual stimulation but not in its absence
PARAPHILIC DISORDERS
Paraphilic disorder: Recurrent sexual attraction to unusual objects or activities, lasting at least
6 months – Distress, impairment, and engagement of nonconsenting others are important
boundaries between normative and problematic sexual behaviour – Some of the paraphilias do
not involve nonconsenting others
Paraphilic disorders are more common among heterosexual males
CLINICAL DESCRIPTIONS (PARAPHILIC DISORDERS)
