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SEXUAL DYSFUNCTIONS,
GENDER DYSPHORIA
&
PARAPHILIC DISORDERS
Sexual Dysfunctions: referred to sexual pain
or to a disturbance in one or more phases of
sexual response cycle.
Or :
heterogeneous group of disorders that are
typically characterized
by a clinically significant disturbance in a
person's ability to respond sexually or to
experience sexual pleasure.
Normal Sexual Response Cycle


Desire – interest in sexual activity, sexual fantasies
Excitement/ Arousal
Men – erection
Women – vaginal lubrication, clitoral erection, labial swelling,
elevation of uterus

Plateau
Men – increase size of testicle, tightening of scrotal sac,
secretion of a few drops of seminal fluid
Women - contraction and relaxation of specific part in vagina


Orgasm
Resolution
Dysfunction may occur at one or more of these phases.
Lifelong – present from first sexual
experiences
Acquired – develop after a period of relatively
normal sexual function
Generalized – not limited to certain types of
stimulation, situations, or partners
Situational – only occur with certain types of
stimulation, situations, or partners
Number of factors must be considered during the assessment of
sexual dysfunction, given that they may be relevant to etiology
and/or treatment, and that may contribute, to varying degrees,
across individuals:
1) partner factors (e.g., partner's sexual problems; partner's health
status);
2) relationship factors (e.g., poor communication; discrepancies in
desire for sexual activity);
3) individual vulnerability factors (e.g., poor body image; history of
sexual or emotional abuse), psychiatric comorbidity (e.g.,
depression, anxiety), or stressors (e.g., job loss, bereavement);
4) cultural or religious factors (e.g., inhibitions related to prohibitions
against sexual activity or pleasure; attitudes toward sexuality);
and
5) medical factors relevant to prognosis, course, or treatment.
Sexual Changes With Aging
Aging may be associated with a normative
decrease in sexual response
 Men usually require more direct stimulation of
genitals and more time to achieve orgasm. The
intensity of ejaculation usually decrease, and
the length of refractory period increase
 After menopause, women experience vaginal
dryness and thinning due to decrease estrogen.
These conditions can be treated with hormone
replacement therapy or vaginal creams

Type of Dysfunctions:
 Male hypoactive sexual desire (desire)
 Erectile disorder (excitement)
 Female sexual interest arousal disorder
(desire & excitement)
 Female orgasm disorder (orgasm)
 Premature ejaculation (orgasm)
 Delayed ejaculation (orgasm)
 Genito-pelvic pain penetration disorder
 Substance/ med induced
A)
B)
C)
D)
Male Hypoactive Sexual Desire Disorder (Desire)
Persistently or recurrently deficient (or absent) sexual/
erotic thoughts or fantasies and desire for sexual activity.
The judgement of deficiency is made by the clinician,
taking into account factors that affect sexual functioning,
such as age and general and sociocultural contexts of
the individual’s life
The symptoms in Criterion A have persisted for a
minimum duration of approximately 6 months
The symptoms in Criterion A cause clinically significant
distress in the individual
The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of
severe relationship distress or other significant stressors
and is not attributable to the effects of a substance/
medication or another medical condition
Male Erectile Disorder (Arousal)
A.
At least 1 of the 3 following symptoms must be experienced
on almost all or all occasions of sexual activity:
A.
B.
C.
B.
C.
D.
Marked difficulty in obtaining an erection during sexual activity
Marked difficulty in maintaining an erection until the completion of sexual
activity
Marked decrease in erectile rigidity
Symptoms persisted for a minimum duration of
approximately 6 months
Cause clinically significant distress in individual
The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of severe
relationship distress or other significant stressors and is not
attributable to the effects of a substances/ medication or
another medical condition
Differential Diagnosis
 Nonsexual mental disorder. Major
depressive disorder and erectile disorder
are closely associated
 Normal erectile function
 Substance/medication use
 Another medical condition.
A.
I.
II.
III.
IV.
V.
VI.
Female Sexual Interest/ Arousal Disorder
(Desire&Arousal)
Lack of, or significantly reduced, sexual interest/
arousal, as manifested by at least 3 of the following :
Absent/ reduced interest in sexual activity
Absent/ reduced sexual/ erotic thoughts or fantasies
No/ reduced initiation of sexual activity, and typically
unreceptive to a partner’s attempts to initiate
Absent/ reduced sexual excitement/ pleasure during
sexual activity
Absent/ reduced sexual interest/ arousal in
response to any internal or external sexual/ erotic
cues (eg written, verbal, visual)
Absent/ reduced sexual genital or nongenital
sensations during sexual activity
B.
C.
D.
Persists for a minimum duration of
approximately 6 months
Cause clinically significant distress in
individual
The sexual dysfunction is not better
explained by a nonsexual mental disorder or
as a consequence of severe relationship
distress (eg partner violence) or other
significant stressors and is not attributable
to the effects of a substance/ medication or
another medical condition
Orgasmic Disorders
 Female Orgasmic Disorder
 Delayed ejaculation
 Premature ejaculation
Female Orgasmic Disorder
Inability to achieve orgasm after a normal excitement phase
I.
Presence of either of the following symptoms and
experienced on almost all occasions of sexual activity
 marked delay in, marked infrequency of, or absence
of orgasm
 markedly reduced intensity of orgasmic sensations
II.
Persistent for at least 6 months
III.
Cause clinically significant distress
IV. The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of severe
relationship distress (eg partner violence) or other
significant stressors and is not attributable to the effects of
a substance/ medication or another medical condition

Delayed Ejaculation
Following symptoms must be experiences on almost all/ all
occasions of partner sexual activity, and without the
individual desiring delay :
A.
I.
II.
B.
C.
D.
Marked delay in ejaculation
Marked infrequency or absence of ejaculation
Persist for at least 6 months
Cause clinically significant distress
The sexual dysfunction is not better explained by a
nonsexual mental disorder or as consequence of severe
relationship distress or other significant stressors and is
not attributable to the effects of a substance/ medication or
another medical condition
Differential Diagnosis
 Another medical condition: A situational aspect to the
complaint is suggestive of a psychological basis for the
problem (e.g., men who can ejaculate during sexual
activity with one sex but not the other; men who can
ejaculate with one partner but not another of the same
sex; or men with paraphilic arousal patterns) … Another
medical illness or injury may produce delays in ejaculation
independent of psychological issues. For example,
inability to ejaculate can be caused by interruption of the
nerve supply to the genitals, such as can occur after
traumatic surgical injury
 Substance/medication use
 Dysfunction with orgasm.





Premature Ejaculation
Ejaculation earlier than desired time.
A persistent or recurrent pattern of ejaculation
occurring during partnered sexual activity within
approximately 1 minutes following vaginal
penetration and before the individual wishes it
Must have been present for at least 6 months and must
be experienced on almost all or all occasions of sexual
activity
The symptom in Criterion A causes clinically significant
distress
The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of severe
relationship distress or other significant stressors and is
not attributable to the effects of a substance medication or
another medical condition

I.
II.
III.



Genito-pelvic Pain/ Penetration Disorder
Persistent or recurrent difficulties with one (or more)
of the following
Vaginal penetration during intercourse
Marked vulvovaginal or pelvic pain during vaginal
intercourse or penetration attempts
Marked fear or anxiety about vulvovaginal or pelvic pain in
anticipation of, during, or as a result of vaginal penetration
Persist for at least 6 months
Cause clinically significant distress
The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of a
severe relationship distress or other significant
stressors and is not attributable to the effects of a
substance/ medication or another medical condition
Substance/Medication-Induced Sexual
Dysfunction
A.
B.
C.
A clinically significant disturbance in sexual function is predominant in
the clinical picture
There is evidence from the history, physical examination, or laboratory
findings of both
(1) and (2):
1.
2.
D.
E.
F.
The symptoms in Criterion A developed during or soon after substance
intoxication or withdrawal or after exposure to a medication
The involved substance medication is capable of producing the symptoms in
criterion A
The disturbance is not better explained by a sexual
dysfunction that is not substance/ medication induced
The disturbance does not occur exclusively during the course of
a delirium
The disturbance causes clinically significant distress
Differential Diagnosis of Sexual Dysfunction
 General
medical condition : Diabetes,
atherosclerosis, pelvic adhesions, alcohol
neuropathy, traumatic surgical surgery to the
lumbar sympathetic ganglia,
abdominoperitoneal surgery, or lumbar
symphatectomy
 Depression
& substance abuse : usage
of anti depressants, antipsychotic, alpha
symphathetic drug, and opiod drugs
 Abnormal
gonadal hormone levels : low
estrogen, low testosterone, high progesterone
Pharmacological Therapy
 Erectile
ᴕ
ᴕ
disorder
Phosphodiesterase-5 inhibitor (sildenafil only)
Alprostadil injected locally
 Premature
ᴕ
ᴕ
ejaculation
SSRIs
TCAs
 Hypoactive
ᴕ
ᴕ
sexual desire disorder
Testosterone (both men and women)
Estrogen (women only)
Treatment of Sexual Disorder
 Dual sex therapy
 Behavior therapy
 Hypnosis
 Group therapy
 Analytically oriented psychotherapy
Mechanical therapy

Male erectile disorders
Vacuum pumps, rings, surgery

Male orgasmic disorder
Gradual progression from extravaginal ejaculation to
intravaginal (masturbation)

Female orgasmic disorder
masturbation (sometimes with vibrator)

Premature ejaculation
Squeezing technique, stop-start technique

Dyspareunia, vaginismus
Gradual desensitization, muscle relaxation, dilators
GENDER DYSPHORIA




Gender dysphoria is a new diagnostic class in DSM-5, is a unique
condition in that it is a diagnosis made by mental health care
providers.
People with this disorder have the subjective feeling that they
were born the wrong sex. They may dress as the opposite sex,
take sex hormones, or undergo sex change operations.
Transgender refers to the broad spectrum of individuals who
transiently or persistently identify with a gender different from their
natal gender.
Transsexual denotes an individual who seek or undergone, a
social transition from male to female, or female to male, which is
involving a somatic transition by cross-sex hormone treatment
and genital surgery (sex reassignment surgery).
Gender dysphoria refers to the distress that
may accompany incongruence between
one’s experienced or expressed gender and
one’s assigned gender.
 Gender assignment refers to the initial
assignment as male and female. This occurs
usually at birth and, thereby, yields the natal
gender.
 Gender reassignment denotes an official
change of gender.

Prevalence


1 in every 30,000 males
1 in every 100,000 females
Differential diagnosis
•
•
•
•
Non conformity to gender role
Transvestic disorder
Body dysmorphic disorder
Schizophrenia and other psychotic disorders
Gender Dysphoria in Children

A. A marked incongruence between one’s experienced/expressed
gender and assigned gender, of at least 6 months duration, as
manifested by at least six of the following (one of which must be
Criterion A1):

1. A strong desire to be of the other gender or an insistence that one is the
other gender (or some alternative gender different from one’s assigned gender).

2. In boys (assigned gender), a strong preference for cross-dressing or
simulating female attire: or in girls (assigned gender), a strong preference for
wearing only typical masculine clothing and a strong resistance to the
wearing of typical feminine clothing.

3. A strong preference for cross-gender roles in make-believe play or fantasy
play.

4. A strong preference for the toys, games, or activities stereotypically
used or engaged in by the other gender.

5. A strong preference for playmates of the other gender.

6. In boys (assigned gender), a strong rejection of typically masculine
toys, games, and activities and a strong avoidance of rough-andtumble play; or in girls (assigned gender), a strong rejection of typically
feminine toys, games, and activities.

7. A strong dislike of one’s sexual anatomy.

8. A strong desire for the primary and/or secondary sex
characteristics that match one’s experienced gender.


B. The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of functioning.
Gender Dysphoria in Adoslescents and Adults

A. A marked incongruence between one’s
experienced/expressed gender and assigned gender,
of at least 6 months duration, as manifested by at least
two of the following:

1. A marked incongruence between one’s experienced/expressed
gender and primary and/or secondary sex characteristics (or in
young adolescents, the anticipated secondary sex characteristics).

2. A strong desire to be rid of one’s primary and/or secondary sex
characteristics because of a marked incongruence with one’s
experienced/expressed gender (or in
young adolescents, a desire to prevent the development of the
anticipated secondary sex characteristics).


3. A strong desire for the primary and/or secondary sex characteristics
of the other gender.

4. A strong desire to be of the other gender (or some alternative
gender different from one’s assigned gender).

5. A strong desire to be treated as the other gender (or some
alternative gender different from one’s assigned gender).

6. A strong conviction that one has the typical feelings and
reactions of the other gender (or some alternative gender
different from one’s assigned gender).

B. The condition is associated with clinically significant
distress or impairment in social, occupational or other
important areas of functioning.
Treatment
 Psychotherapy.
 Family involvement for young patients.
 Sex reassignments by hormonal and surgical
techniques for adults.
Homosexuality
Sexual Orientation : The direction of one’s
romantic interests and erotic attraction
towards a member of the same gender, the
other gender or both.
Homosexuality : Erotic attraction to and
interest in forming romantic relationships
with members of one’s own gender (Gays,
lesbians)

Homosexuality is a sexual or a romantic desire for people of the same sex

It’s not a sexual disorder and is a normal variant of sexual orientation

True incidence is unknown (< 10 % in both sexes)

The etiology is unknown. Homosexuality was once thought to be the result of
troubled family dynamic or faulty psychological development

Prepubertal same-sex exploratory activities are common and do not significantly
latent homosexuality

May develop MDD if experiences severe distress because of the conflict
between their sexuality and the values of society. Gay and lesbian are often
taunted and humiliated in their school/ work settings.

Homophobia is a term that refers to the irrational fear and prejudice against
homosexual persons
Paraphilic disorders






Paraphilias are sexual disorder characterized by
engagement in unusual sexual activities and/or
preoccupation with unusual sexual urges or fantasies
At least 6 months that cause impairment in daily
functioning
Intense, recurrent and interfere with daily life
Occasional fantasies are considered normal
Most paraphilias occur only in men, but sadism,
masochism and pedophilia may also occur in women
The most common paraphilias are pedophilia, voyeurism,
and exhibitionism
Common Paraphilias
o
o
o
o
o
o
o
o
o
o
Pedophilia
Frotterurism
Voyerurism
Exhibitonism
Sadism
Fetishism
Transvestic fetischism
Masochism
Necrophilia
Telephone scatologia
Exhibitionism
Diagnostic criteria :
A.
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges, or behaviors involving the exposure of
one's genitals to an unsuspecting stranger.
B.
The person has acted on these sexual urges,
or the sexual urges or fantasies cause marked
distress or interpersonal difficulty.
Voyeurism
Diagnostic criteria :
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges, or behaviors involving the act of
watching unsespecting nude individuals
(often with binocular) to obtain sexual
pleasure.
B. The person has acted on these sexual urges,
or the sexual urges or fantasies cause marked
distress or interpersonal difficulty.
A.
Sadism
Diagnostic criteria :
A.
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges from hurting or humiliating another.
B.
The person has acted on these sexual urges,
or the sexual urges or fantasies cause marked
distress or interpersonal difficulty.
Masochism
Diagnostic criteria :
A.
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges, or behaviors involving the act (real, not
simulated) of being humiliated, beaten,
bound, or otherwise made to suffer.
B.
The fantasies, sexual urges, or behaviors
cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
Frotteurism
Diagnostic criteria :
A.
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges, or behaviors involving touching and
rubbing against a non-consenting person.
B.
The fantasies, sexual urges, or behaviors
cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
Pedophilia
Diagnostic criteria :
A.
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).
B.
The person has acted on these sexual urges, or the sexual urges
or fantasies cause marked distress or interpersonal difficulty.
C.
The person is at least age 16 years and at least 5 years older
than the child or children in Criterion A.
Pedophilia
 Majority involve fondling and oral sex
 Penetration is infrequent except in incest
 Offenders report 60% of victims are boys but
victim reports are most often girls
 Most offenders are usually relatives of the
victims
Fetishism
Diagnostic criteria :
A.
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges, or behaviors involving the use of
nonliving objects (e.g., female
undergarments).
B.
The fantasies, sexual urges, or behaviors
cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
Transvestic Fetishism
Diagnostic criteria
A.
Over a period of at least 6 months, recurrent,
intense sexually arousing fantasies, sexual
urges, or behaviors involving cross-dressing.
B.
The fantasies, sexual urges, or behaviors
cause clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.

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