Because learning changes everything.

Abnormal Psychology
9th Edition

Susan Nolen-Hoeksema
Yale University

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 Chapter 13: Sexual Disorders and
Gender Diversity

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 Chapter Outline
Sexual Dysfunctions.
Paraphilic Disorders.
Gender Dysphoria.

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 Sexuality
Sexual functioning: What happens in the body during sexual
activity.
Gender identity: Individuals’ perception of themselves as male,
female, another gender, or without gender.

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 Figure 1
The Sexual Response Cycle.

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© McGraw Hill LLC Source: Masters & Johnson, 1970. 5

 Sexual Dysfunctions
Set of disorders in which people have difficulty responding
sexually or experiencing sexual pleasure.
To be diagnosed problems must:
• Occur most of the time for at least 6 months.
• Cause significant distress or impairment.
• Not be due to another nonsexual psychiatric problem.

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 TABLE 1 DSM-5 Sexual Dysfunctions
Table 1 DSM-5 Sexual Dysfunctions*
The sexual dysfunction disorders can be roughly divided into disorders of sexual desire and arousal and disorders of
orgasm and sexual pain. If a sexual dysfunction is caused by a substance (e.g., alcohol) or medication, it is given the
diagnosis substance/medication-induced sexual dysfunction. All sexual dysfunctions (except substance/medication-
induced sexual dysfunction) require a minimum duration of approximately 6 months.
Disorder Description
Disorders of Sexual
Interest/Desire or Arousal
Female sexual interest/arousal Persistent lack of, or significantly reduced, interest in sexual activity and/or lack of arousal in
disorder response to sexual activity.
Male hypoactive desire disorder Persistently absent or deficient sexual/erotic thoughts or fantasies, or desire for sexual
activity.
Erectile disorder Recurrent inability to attain or maintain an erection or a marked decrease in erectile rigidity.
Disorders of Orgasm or Sexual
Pain
Female orgasmic disorder Reduced intensity, or recurrent delay or absence of orgasm during sexual activity
Early ejaculation Recurrent ejaculation within 1 min of initiation of partnered sexual activity when not desired
Delayed ejaculation Marked delay, infrequency, or absence of ejaculation during sexual encounters
Genito-pelvic pain/penetration Marked difficulties having vaginal penetration; pain or tightening of pelvic floor muscles
disorder during penetration
*The information presented in this table is based solely on the author’s interpretation of DSM-5. It does not reflect the exact language that
appears in DSM-5 and is not, therefore, formally endorsed by the APA.
Source: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association, 2013.

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 Biological Causes of Sexual Dysfunctions
Medical illnesses.
Abnormally low levels of the androgen hormones or high levels
of the hormones estrogen and prolactin in men.
For women antihistamines, douches, tampons, vaginal
contraceptives, radiation therapy, endometriosis, and infections
can cause vaginal dryness.
Prescription drugs.
Substance-induced sexual dysfunction:
• Recreational drugs.
• Alcohol.

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 Psychological Causes of Sexual Dysfunctions
Mental disorders.
• Symptoms of the disorders.
• Side effects of medications.

Attitudes and cognitions.

• Performance anxiety: Worrying about being aroused and having an
orgasm to the extent that it interferes with sexual functioning.

Trauma.

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 Figure 2
A Model Showing How Anxiety and Cognitive Interference Can Produce
Erectile Dysfunction and Other Sexual Disorders.
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 Interpersonal Factors Affecting Sexual Dysfunctions
Conflicts about a couple's sexual activities.
Anorgasmia and lack of communication.
Inhibition in discussing stimulations.
Conflicts other than sex.
• Anger, distrust, and lack of respect for one’s partner.

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 Cultural Factors Affecting Sexual Dysfunctions
Different beliefs about sexual dysfunctions.
Varied sexual preferences.
Some cultures promote negative attitudes toward sex.
Gender roles.
Lower educational and income.
• Lack of knowledge.
• Increased stress.
• Poor physical health.

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 Trends Across the Life Span
Age-related biological changes affect sexual functioning.
• Low testosterone levels in men.
• Diminished estrogen levels in women.
• Medical conditions.
• Loss of loved ones.

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 Biological Therapies for Sexual Dysfunctions
Sildenafil—Viagra and other ED drugs.
Antidepressants.
Mechanical interventions.
• Do not evoke bodily or mental feelings of sexual arousal.

Hormone therapy.

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 Psychotherapy and Sex Treatments for Sexual
Dysfunctions 1
Individual and couples therapy.
• Cognitive-behavioral interventions.
• Goal—Resolving differences.

Sex therapy.
• Behavioral techniques to improve skills and comfort.

Sensate focus therapy: Three phase process of getting over

sexual dysfunction.

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 Psychotherapy and Sex Treatments for Sexual
Dysfunctions 2
Techniques for treating early ejaculation.
• Stop-start technique: Alternating stimulation to avoid early ejaculation.
• Squeeze technique: Pressing the penis to cause partial loss of erection.
Techniques for treating pelvic muscle tightening.
• Deconditioning the woman’s automatic tightening of her vaginal muscles.

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 Considerations for LGBTQI People
LGBTQI people face additional stressors.
• Stigma and discrimination.

Gender dysphoria causes psychological distress.

Sexual violence and transphobia affect many.

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 Paraphilic Disorders
Atypical sexual preferences that:
• Cause significant distress or impairment.
• Entail personal harm or risk of harm to others.

Types of paraphilias.
Involve:
• Nonhuman objects.
• Nonconsenting adults.
• Suffering or humiliation of oneself or one’s partner.
• Children.

DSM-5-TR definitions and diagnosis are highly controversial.

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 Fetishistic Disorder and Transvestic Disorder
Fetishistic disorder: Use of nonliving objects or nongenital body
parts for sexual arousal or gratification.
Urges must be causing significant distress or impairment.
• More common in men.
• Transvestic disorder: Dressing in the clothes of the opposite sex as a
means of becoming sexually aroused.
• The clothes themselves are not arousing—dressing in the clothes is arousing.
• Behavior tends to start before puberty.
• Most affected men are married with children.

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 Sexual Sadism and Sexual Masochism Disorders
Sexual sadism disorder—Sexual fantasies, urges, or behaviors
that involve inflicting pain and humiliation on the sex partner.
Sexual masochism disorder—Sexual fantasies, urges, or
behaviors that involve personally enduring pain or humiliation
during sex.
For diagnosis the urges must:
• Cause distress or impairment, or
• Urges acted upon with nonconsenting person.

More common in men.

• Urges must be causing significant distress or impairment.

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 Voyeuristic, Exhibitionistic Disorders
Voyeurism—Watching an unsuspecting person undress, do
things in the nude, have sex, or engage in activities that are
considered private.
Voyeuristic disorder: Voyeuristic behavior repeated over 6
months and is compulsive.
• Causing significant stress and impairment.

Exhibitionism—Obtaining sexual gratification by exposing

genitals to involuntary observers.
Exhibitionistic disorder: Exhibitionistic behavior causing stress
and impairment.

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 Frotteuristic Disorder
Gaining sexual gratification from rubbing against and fondling
body parts of a nonconsenting person.
Urges must be causing significant distress or impairment.
• May not impair affected individual but causes distress to others.

Frequently co-occurs with voyeurism and exhibitionism.

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 Pedophilic Disorder
Sexual fantasies, urges, and behaviors focused on prepubescent
children.
Can be exclusive (i.e., attracted only to children) or nonexclusive.
May be limited to incest.
Some are threatening and violent toward victims.
• Others are loving and gentle as a way of gaining trust.

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 Causes of Paraphilias 1
Behavioral theories.
• Initial classical pairing of intense early sexual arousal with a particular
stimulus.
• Strong sex drive that pairs fantasies with sexual gratification.
Social learning theory.
Larger environment of a child’s home and culture.
• Corporal punishments.
• Sexual abuse.

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 Causes of Paraphilias 2
Cognitive theories.
Alterations in the development of the brain and hormonal systems.
• Head injury before the age of 13.
• Cognitive and memory deficits.
• Lower intelligence.
• Differences in brain structure volume.

Dysfunctions in the frontal areas of the brain.

• Regulating impulsive and aggressive behavior and in testosterone levels.

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 Figure 3
A Behavioral Account of the Development of Paraphilias.

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 Treatments for the Paraphilias 1
Most do not seek treatment and treatment is often forced after
an arrest.
Biological interventions—aimed at reducing the sex drive.
• Surgical castration.
• Antiandrogen drugs.
• Selective serotonin reuptake inhibitors (SSRIs).

Behavior modification therapies.

• Aversion therapy: Extinguishing sexual responses to objects or
situations a person with a paraphilia finds arousing.
• Desensitization procedures to reduce anxiety about engaging in normal
sexual activities with other adults.

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 Treatments for the Paraphilias 2
Cognitive treatments.
• Help people learn more socially acceptable ways to approach and
interact with people they find attractive.
• Combined with behavioral interventions.
• Group therapy—People support one another.

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 Gender Dysphoria
Discrepancy between individuals' gender identity and their
biological sex.
Gender dysphoria in children—Child persistently rejects their
anatomic sex and desires to be or insists they are a member of
the opposite sex.
Resulting stress often leads to depression, substance abuse,
and/or risky sexual behavior, suicide.
Transgender: A term that refers to the broad spectrum of
individuals who transiently or persistently identify with a gender
different from their natal gender.
Cisgender: An individual whose gender identity aligns with their
natal sex.

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 Contributors to Gender Dysphoria
Biological theories.
Effects of prenatal hormones on brain development.
Female-to-male gender dysphoria in genetic females.
• Hormonal disorders resulting in prenatal exposure to high levels of androgens.

Male-to-female gender dysphoria in genetic males.

• Prenatal exposure to very low levels of androgens.

Bed nucleus of the stria terminalis implicated.

Psychosocial theories.
• Focus on the role parents play in shaping their children’s gender identity.

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 Treatments for Gender Dysphoria
Therapy goal is to help individuals clarify their gender identity
and desire for treatment.
• Address secondary interpersonal and psychological issues.

Cross-sex hormone therapy.

Full-time real-life experience in the desired gender role.
Gender affirming surgery.

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 Figure 4
Interplay of Biological, Psychological, and Social Factors in Sexuality.

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