Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders
I. Sexual Dysfunctions
A. Definition.
Sexual function is affected by a complex interaction of factors. A person’s sexuality is enmeshed with other personality factors, with one’s biological makeup and with a general sense of self. A problem in one of more of these areas can result in sexual dysfunction. The final common pathway to dysfunction is performance anxiety, which inhibits sexual response and tends to perpetuate the sexual problem. The dysfunctions can be a lifelong type or an acquired type (i.e., developing after a period of normal functioning); a generalized type or situational type (i.e., limited to a certain partner or a specific situation); and the consequence of physiological factors, psychological factors, or combined factors.
In Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) a sexual dysfunction is defined as a disturbance in the sexual response cycle or as pain with sexual intercourse. Seven major categories of sexual dysfunction are listed in DSM-IV-TR: sexual desire disorders, sexual arousal disorders, orgasm disorders, sexual pain disorders, sexual dysfunction caused by a general medical condition, substance-induced sexual dysfunction, and sexual dysfunction not otherwise specified. Table 18-1 lists each DSM-IV-TR phase of the sexual response cycle and the sexual dysfunctions usually associated with it.
B. Sexual desire disorders.
Sexual desire disorders are divided into two classes: hypoactive sexual desire disorder, characterized by a deficiency or absence of sexual fantasies and the desire for sexual activity, and sexual aversion disorder, characterized by an aversion to and avoidance of genital sexual contact with a sexual partner or an avoidance of masturbation.
Patients with desire problems may use inhibition of desire defensively to protect against unconscious fears about sex. A lack of desire can also accompany chronic anxiety or depression, or the use of various psychotropic drugs and other drugs that depress the central nervous system (CNS). In sex therapy clinic populations, lack of desire is one of the most common complaints among married couples, with women more affected than men.
C. Sexual arousal disorders.
The sexual arousal disorders are divided by DSM-IV-TR into female sexual arousal disorder, characterized by the persistent or recurrent partial or complete failure to attain or maintain the lubrication-swelling response of sexual excitement until the completion of the sexual act, and male erectile disorder, characterized by the recurrent and persistent partial or complete failure to attain or maintain an erection until completion of the sex act.
Table 18-1 DSM-IV-TR Phases of the Sexual Response Cycle and Associated Sexual Dysfunctionsa | ||||||||||||||||||
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Women. The prevalence of female sexual arousal disorder is generally underestimated. In one study of subjectively happily married couples, 33% of women described arousal problems. Difficulty in maintaining excitement can reflect psychological conflicts (e.g., anxiety, guilt, and fear) or physiological changes. Alterations in levels of testosterone, estrogen, prolactin, serotonin, dopamine, and thyroxin have been implicated in arousal disorders, as have antihistamine medications. See Table 18-2.
Men. The prevalence of erectile disorder, or impotence, in young men is estimated at 8%. This disorder may first appear later in life. A number of procedures, from benign to invasive, are used to differentiate organically (i.e., physiologically) caused impotence from functional (i.e., psychological) impotence. The most commonly used procedure is monitoring of nocturnal penile tumescence (erections that occur during sleep), normally associated with rapid eye movement (REM) sleep. See Table 18-3.
A good history is invaluable in determining the cause. A history of spontaneous erections, morning erections, or good erections with masturbation or with partners other than the usual one indicates functional
impotence. Psychological causes of erectile dysfunction include a punitive conscience or superego, an inability to trust, or feelings of inadequacy. Erectile dysfunction also may reflect relationship difficulties between partners.
Table 18-2 DSM-IV-TR Diagnostic Criteria for Female Sexual Arousal Disorder | |||||
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D. Orgasmic disorders
Female. See Table 18-4. Female orgasmic disorder (anorgasmia) is a recurrent or persistent delay in or absence of orgasm following a normal sexual excitement phase. The estimated proportion of married women over age 35 who never have achieved orgasm is 5%. The proportion is higher in unmarried women and younger women. The overall prevalence
of inhibited female orgasm is 30%. Psychological factors associated with inhibited orgasm include fears of impregnation or rejection by the sex partner, hostility toward men, feelings of guilt about sexual impulses, or marital conflicts.
Table 18-3 DSM-IV-TR Diagnostic Criteria for Male Erectile Disorder
- Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.
- The disturbance causes marked distress or interpersonal difficulty.
- The erectile dysfunction is not better accounted for by another Axis I disorder (other than a sexual dysfunction) and is not due exclusively to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Specify type:
- Lifelong type
- Acquired type
Specify type:
- Generalized type
- Situational type
Specify:
- Due to psychological factors
- Due to combined factors
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.
Table 18-4 DSM-IV-TR Diagnostic Criteria for Female Orgasmic Disorder
- Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of female orgasmic disorder should be based on the clinician’s judgment that the woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives.
- The disturbance causes marked distress or interpersonal difficulty.
- The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another sexual dysfunction) and is not due exclusively to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Specify type:
- Lifelong type
- Acquired type
Specify type:
- Generalized type
- Situational type
Specify:
- Due to psychological factors
- Due to combined factors
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text rev. Washington, DC: American Psychiatric Association; 2000, with permission.
- Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection.
Male. In male orgasmic disorder (inhibited male orgasm), the man achieves ejaculation during coitus with great difficulty, if at all. Lifelong inhibited male orgasm usually indicates more severe psychopathology. Acquired ejaculatory inhibition frequently reflects interpersonal difficulties. The most common biological reason for this condition is treatment with selective serotonin reuptake inhibitors (SSRIs), which cause delayed orgasm.
Premature ejaculation. Premature ejaculation is the chief complaint of 35% to 40% of men treated for sexual disorders. The man persistently or recurrently achieves orgasm and ejaculates before he wishes to. It is more prevalent among young men, men with a new partner, and college-educated men than among men with less education; the problem with the latter group is thought to be related to concern for partner satisfaction.
Difficulty in ejaculatory control may be associated with anxiety regarding the sex act and with unconscious fears about the vagina. It may also be the result of conditioning if the man’s early sexual experiences occurred in situations in which discovery would have been embarrassing. A stressful marriage exacerbates the disorder.
This dysfunction is the one most amenable to cure when behavioral techniques are used in treatment. However, a subgroup of premature ejaculators may be biologically predisposed; they are more vulnerable to sympathetic stimulation or they have a shorter bulbocavernosus reflex nerve latency time, and they should be treated pharmacologically with SSRIs or other antidepressants. A side effect of these drugs is the inhibition of ejaculation.
E. Sexual pain disorders
Vaginismus. Vaginismus is an involuntary muscle constriction of the outer third of the vagina that interferes with penile insertion and intercourse. This dysfunction most frequently afflicts women in higher socioeconomic groups. A sexual trauma, such as rape or childhood sexual abuse, can be the cause. Women with psychosexual conflicts may perceive the penis as a weapon. A strict religious upbringing that associates sex with sin or problems in the dyadic relationship are also noted in these cases.
Dyspareunia. Dyspareunia is recurrent or persistent genital pain occurring before, during, or after intercourse. Medical causes (endometriosis, vaginitis, cervicitis, and other pelvic disorders) must be ruled out in patients with this complaint.
Chronic pelvic pain is a common complaint in women with a history of rape or childhood sexual abuse. Painful coitus may result from tension and anxiety. Dyspareunia is uncommon in men and is usually associated with a medical condition (e.g., Peyronie’s disease).
F. Sexual dysfunction due to a general medical condition
Male erectile disorder. Statistics indicate that erectile disorder is medically based in 50% of affected men. Medical causes of male erectile dysfunction are listed in Table 18-5.
Dyspareunia. Pelvic disease is found in 30% to 40% of women with this complaint who are seen in sex therapy clinics. An estimated 30% of surgical procedures on the female pelvic or genital area also result in temporary dyspareunia. In most cases, however, dynamic factors are considered causative.
Medical conditions leading to dyspareunia include irritated or infected hymenal remnants, episiotomy scars, infection of a Bartholin’s gland, various forms of vaginitis and cervicitis, endometriosis, and postmenopausal vaginal atrophy.
Hypoactive sexual desire disorder. Desire commonly decreases after major illness or surgery, particularly when the body image is affected after such procedures as mastectomy, ileostomy, hysterectomy, and prostatectomy. Drugs that depress the CNS, decrease testosterone or dopamine concentrations, or increase serotonin or prolactin concentrations can decrease desire.
Other male sexual dysfunctions. Male orgasmic dysfunction may have physiological causes and can occur after surgery on the genitourinary tract. It may also be associated with Parkinson’s disease and other neurological disorders involving the lumbar or sacral sections of the spinal cord. Certain drugs (e.g., guanethidine monosulfate [Ismelin]) have been implicated in retarded ejaculation (Table 18-6).
Other female sexual dysfunctions.Related posts:
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