Chapter 13.  Sexual Disorders

Slide 1: How do diagnoses get in there anyway?

• Let's reexamine the actions of the Task Force on the DSM in their decision to remove homosexuality from the DSM in 1973.  (Homosexuality was a diagnosis in the DSM-II.  Ego-dystonic homosexuality alone was a diagnosis in the DSM-III.  It is completely absent in the DSM-IV.)  As members of the new executive council:
• Consider the data you would want to assist your decision making process to either include or exclude this diagnosis.
• Develop a list of criteria that would assist your group in making wise decisions about the inclusion or exclusion of any disorder.  (For example, there are a number of diagnoses included in the appendix that are being studied for possible inclusion in future editions of the DSM, e.g., premenstrual dysphoric disorder.)

Slide 2: Oppression and privilege

• What do you think caused your heterosexuality?
• When and how did you first decide you were heterosexual?
• Is it possible your heterosexuality is just a phase you may grow out of?
• Is it possible that your heterosexuality stems from a neurotic fear of others of the same sex?
• If you've never slept with a person of the same sex, is it possible that all you need is a good gay lover?
• To whom have you disclosed your heterosexual tendencies?
• Heterosexual Questionnaire

Slide 3: Pros

• Most homosexuals seen by clinicians were maladjusted (which is why they were going to see them), therefore we equated homosexuality and maladjustment
• Behavior countered the values of the times
• Behavior was seen as unusual (thus deviant)

Slide 4: Cons: Mental health

• Nonclinical samples of homosexuals: Same range of mental health as in heterosexual population
• Hooker :
• Psychologists could not identify gays from a blind Rorschach
• Are not identified as less well-adjusted
• Often bizarre comparisons in literature: Gay servicemen in detention & waiting for discharge with straight population

Slide 5: Cons: Invariant values?

• Some cultures have prohibited homosexuality, but others have encouraged it.
• We have perceived other things as "abnormal" in the past and currently accept them as within normal experience
• Homosexual behavior, in some form, has been found in every species

Slide 6: Cons: Frequencies

• Frequencies:
• 10% of MM self-described as gay (Kinsey, Pomeroy, & Martin, 1948)
• 37% of MM had at least one homosexual experience leading to orgasm as an adolescent.  (Kinsey et al., 1948)
• Note that this was an unusual population, probably biased towards more sexual behavior and more experimentation!
• Billy, Tanfer, Grady, & Klepinger (1993) note that 2.3% reported engaging in homosexual activity, 1.1% exclusively homosexual activity.
• Kinsey described sexuality as being on a continuum rather than dichotomous choices.

Slide 7: What issues for therapy?

• Acceptance of sexual orientation
• Little evidence that a gay male population can change their orientation.
• Easiest to change sexual orientation of bisexual population
• Homophobia and internalized homophobia
• Support
• Lesbians are more likely to get from other lesbians
• Heterosexual FF are more likely to get from family
• AIDS
•  All the normal stuff

Slide 8: What's normal?

Slide 9: A Case of Sexual Desire

• Marcella (28) and her partner arrive in your office complaining that they never have sex any more.  They are both in generally good health, employed, and have three healthy children.
• "Never have sex any more" could be due to several different sorts of problems.  Which disorders would you think about?  Why?
• You decide that you are going to use an interview to assess the nature of the problem(s) they are facing.  What kinds of questions would you include?  Why?

Slide 10: Semistructured interview (Barlow & Durand, 1995)

• How would you describe your current interest in sex?
• Do you avoid engaging in sexual behavior with your/a partner?
• Do you have sexual fantasies?
• How often do you currently masturbate?
• How frequently do you currently engage in sexual intercourse?
• How often do you engage in mutual caressing or "cuddling" without intercourse?
• Have you ever been sexually abused, raped, or had a very negative experience associated with sex?
• Do you have problems attaining/getting an erection or Do you have problems achieving/maintaining lubrication of your vagina?
• Do you ever have problems reaching orgasm during sex?
• Do you ever experience pain associated with sexual activity?

Slide 11: Disorders of desire: Hypoactive sexual desire disorder (APA, 1994)

(A) persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity.  The judgment
      of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning,
      such as age and the context of the person's life;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) the sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual
       Dysfunction) and is not due exclusively to the direct physiological effects of a substance or a general
       medical condition.

Slide 12: Disorders of desire: Hypoactive sexual desire disorder (APA, 1994)

• Very difficult to assess.
• Frequency of initiation?
• Thoughts about sex?
• What if they engage in sex although not aroused?  What's normal?
• Over 50% of P going to sex therapy clinics go for this issue
• Perhaps 25% of general population have this problem

Slide 13: Disorders of desire: Sexual aversion disorder (APA, 1994)

(A) persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact
      with a sexual partner;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) the sexual dysfunction is not better accounted for by another Axis I disorder (except another
       Sexual Dysfunction).
                                                    p. 561

Slide 14 Disorders of desire: Sexual aversion disorder (APA, 1994)

• Thought of engaging in sex cause feelings of fear, panic, disgust
• Panic disorder is commonly co-morbid
• Between 10 - 25% of this population have both

Slide 15: Disorders of arousal: Female sexual arousal disorder (APA, 1994)

(A) persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate
       lubrication-swelling response of sexual excitement;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) the sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual
      Dysfunction) and is not due exclusively to the direct physiological effects of a substance or a general
      medical condition.
                                                    p. 562

Slide 16: Disorders of arousal: Female sexual arousal disorder (APA, 1994)

• Not a disorder of desire, as have frequent urges and fantasies, but of arousal (maintaining an erection or becoming lubricated)
• May be lifelong or acquired and situational
• 40% of a normal population reported occasional erectile problems
• 63% of FF reported problems with arousal & orgasm, but that these did not interfere withoverall sexual satisfaction (Frank et al., 1978)  In other words, often a discordance between sexual functioning & sexual satisfaction

Slide 17: Disorders of arousal: Male erectile disorder (APA, 1994)

(A) persistent or recurrent inability to attain, or to maintain until completion of the sexual activity,
      an adequate erection;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) 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 physiological effects of a substance or a general
       medical condition.
                                                        p. 563

Slide 18: Orgasmic disorders: Female orgasmic disorder (APA, 1994)

(A) 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;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) 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 physiological effects of a substance or a general
       medical condition.
                                                        p. 563

Slide 19: Orgasmic disorders: Male orgasmic disorder (APA, 1994)

(A) persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during
      sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity,
      and duration;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) 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 physiological effects of a substance or a general
       medical condition.
                                                         p. 565

Slide 20: Orgasmic disorders: Orgasmic disorder (APA, 1994)

• Most common complaint among women seeking therapy.
• About 5-10% of FF in community sample report never or almost never reaching orgasm
• Note: Only 50% regularly reach orgasm
• Between 1 & 10% of MM have delayed or absent orgasm in community sample.

Slide 21: Orgasmic disorders: Premature ejaculation (APA, 1994)

(A) persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration
      and before the person wishes it: The clinician must take into account factors that affect duration of the
      excitement phase, such as age, novelty of the sexual partner or situation, and recent frequency of sexual
      activity;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) the premature ejaculation is not due exclusively to the direct effects of a substance.
                                                        p. 564

Slide 22: Orgasmic disorders: Premature ejaculation (APA, 1994)

• About 37% of community samples, 60% of men entering at least one sex therapy clinic
• What is premature?  This is a valuative statement, but may reflect feelings of loss of control.
• Treated with squeeze technique to junction of head & shaft after full erection to decrease arousal

Slide 23: Pain disorders: Dyspareunia (APA, 1994)

(A) recurrent or persistent genital pain associated with sexual intercourse in either a male or a female;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) the disturbance is not caused exclusively by Vaginismus or lack of lubrication, is not better accounted for by
       another Axis I disorder (except another Sexual Dysfunction), and is not due exclusively to the direct
       physiological effects of a substance or a general medical condition.

Slide 24: Pain disorders: Dyspareunia (APA, 1994)

• Desire, arousal, & orgasm may all be present, but pain of  sex may be so severe that it interrupts sex act.
• Frequencies:
• 1-5% of MM, 11% of FF in community samples
• Rare in clinic

Slide 25: Pain disorders: Vaginismus (APA, 1994)

(A) recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes
      with sexual intercourse;
(B) the disturbance causes marked distress or interpersonal difficulty;
(C) the disturbance is not better accounted for by another Axis I disorder and is not due exclusively to the direct
       physiological effects of a general medical condition.

Slide 26: Pain disorders: Vaginismus (APA, 1994)

• Spasms of vagina during attempted penetration
• 5-10% in American sex clinic samples, 42 - 55% in cultures with more conservative views of sexuality (Ireland)
• Treat by inserting larger & larger dilators (systematic desensitization in vivo)

Slide 27: Sex therapy

• Regardless of problem, very similar solutions:
• Initially sensate focus or nondemand pleasuring
• Then genital pleasuring, no intercourse, orgasm is not goal
• May break down intercourse into smaller steps
• Also generally pay attention to:
• Issues of abuse
• Cognitive distortions about love, relationships and sex
• Relationship problems

Last modified November 16, 2001.