Chapter 10: Sexual and Gender Identity Disorders

Abnormal Psychology: An Integrative Approach, 4th Edition, David H.
Barlow
Chapter 10: Sexual and Gender Identity Disorders
Sexual and Gender Identity Disorders

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
OUTLINE
 1. Sexual Dysfunction Disorders
 Disorders of the Desire Phase
 - Hypoactive Sexual Desire Disorder
 - Sexual Aversion Disorder
 Disorders of the Arousal Stage
 - Female Sexual Arousal Disorder
 - Male Erectile Disorder Disorder
 - (Persistent Sexual Arousal Disorder)
 Disorders of the Orgasm Phase
 - Female Orgasmic Disorder
 - Male Orgasmic Disorder
 - Premature Ejaculation
OUTLINE (cont.)
 1. Sexual Pain Disorders
 Dyspareunia
 Vaginismus
2. Substance Induced Sexual Dysfunction
“Despite a lifetime of service to the cause of

sexual liberation I have never caught a
venereal disease, which makes me feel rather
like an arctic explorer who has never had
frostbite.”
Germaine Greer (1939 - )
Australian-born British writer and academic.
The Observer (London), "Sayings of the Week"

Sexual Dysfunctions: An Overview

 Sexual Dysfunctions
 Affect desire, arousal, and/or orgasm
 Pain associated with sex can lead to additional dysfunction
 Males and Females
 Experience parallel versions of most sexual dysfunctions
 Affects about 43% of all females and 31% of males
 Most prevalent class of disorder in the United States
 Classification of Sexual Dysfunctions
 Lifelong vs. acquired
 Generalized vs. specific
 Psychological factors alone
 Psychological factors combined with medical conditions
Figure 10.3 The human sexual response cycle.

Sexual Desire Disorders
 1. Hypoactive Sexual Desire Disorder

 Low or no sexual desire:
- low or no sexual thoughts and fantasies
- low or no interest in initiating and participating in
sexual activities
- low or no awareness of sexual cues from others
 Accounts for half of all complaints at sexuality clinics
 Diagnosis made considering age and context
 Affects 20-35% of women and 15% of men
Sexual Desire Disorders
 2. Sexual Aversion Disorder

 Active avoidance of sexual activities
 Physical / sexual contact – Extreme fear, panic,
disgust
 10% of males report panic attacks during sexual
activity
 Etiology
-Classically conditioned response
ASSAULT + SEX = FEAR, PANIC,
AVOIDANCE
UCS CS CR
 Hypoactive Sexual Desire Disorder and Sexual

Aversion Disorder
 Etiology
- Biological causes:
(hormonal) testosterone , prolactin , estrogen
(prescription and recreational drugs) antihypertensive,
antipsychotic, antidepressant, cocaine, alcohol, amps
(medical conditions) diabetes, cardiovascular diseases, MS,
Spinal chord injury, ANS injury, renal failure
- Socio-culturaland Psychological causes

Situational pressures, relationship problems,
contradictory cultural standards, psychological
factors, psychological disorders, sexual abuse
Sexual Arousal Disorders

Problem is arousal, not desire
 4. Male Erectile Disorder

 Difficulty achieving and maintaining an erection
 Generally affects about 8-10% of males
 7% at age 40, 18% at 60, 27% at 70, 76% at 80
 Males are more troubled by the problem than
females
 Erectile problems are the main reason males seek
help
 10 of 63 cases of ED were caused
purely psychological factors, only 5
were the result of biological factors
 4. Male Erectile Disorder (cont)

 Etiology
 - Biological causes
 Hormonal abnormalities, vascular abnormalities
 Identifying organic causes: nocturnal penile tumescence
- Socio-cultural and Psychological causes

Job loss and financial stress, relationship problems
*2 Sexual Interaction Patterns
1. Inadequate sexual stimulation to aging husband
2. Only intercourse can give wife an orgasm
*Performance Anxiety and spectator role
Worry on sexual performance = self-evaluative
spectator: aroused participant

 5. Female Sexual Arousal Disorder

 Difficulty achieving and maintaining adequate
lubrication - swelling
 Affects about 10-50% of females
 Lack of sexual arousal is tied with orgasmic
dysfunctioning
 Subjective sexual arousal disorder
 - Absence of or markedly diminished feelings of
 sexual arousal, (sexual excitement and pleasure)
 Genital sexual arousal disorder
 - minimal vulval swelling or vaginal lubrication from
any type of sexual stimulation

 6. Persistent Sexual Arousal Disorder
 “sensations of insistent and persistent vaginal
congestion and other physical signs of sexual
 arousal in the absence of any initial or deliberate
 attempt to invoke desire or arousal”
 • Occasionally relieved by orgasm

 • Distressing, intrusive, and unwanted
 • A newly described syndrome (2001)
Orgasm Disorders
 7. Inhibited Orgasm: Male Orgasmic Disorder
 Have adequate desire and arousal
 Unable to achieve orgasm
 Rare condition in adult males (1-3%)
 Similar to Psychogenic aspermia
 Etiology
 - low testosterone, neurological diseases, head injuries,
and drugs inhibiting arousal of sympathetic NS (fluoxetine)
 - performance anxiety and spectator role, hypoactive
sexual disorder
Orgasm Disorders: An Overview

 8. Inhibited Orgasm: Female Orgasmic Disorder
 Have adequate desire and arousal
 Unable to achieve orgasm
 Most common complaint of adult females
 10-15% never had and/or rarely had an orgasm
 25% of adult females report difficulty reaching orgasm
 50% of adult females report experiencing regular orgasms
 Orgasm during intercourse per se is not critical to normal
sexual functioning
 “clitoral orgasm” and “vaginal orgasm”

 8. Inhibited Orgasm: Female Orgasmic Disorder
 Etiology
 - diabetes, MS, and postmenopausal changes in skin
sensitivity, (size and location of clitoris?)
 - Societal-cultural norms, sexually restrictive upbringing,
 - sexual abuse during childhood (50-70%)
 - unhappy childhood or loss of parent as a child
 - degree of emotional involvement and length of
relationship with partner

 9. Premature Ejaculation
 Ejaculation before the man or partner wishes it to
 Orgasm with minimal stimulation
 21% of all adult males meet diagnostic criteria
 Most prevalent sexual dysfunction in adult males
 Common in younger, inexperienced males
 Problem declines with age and experience
 Retrograde ejaculation is the least

common of the ejaculation problems.
It causes semen to back into the
bladder during orgasm instead
of exiting by way of the penis.
Sexual Pain Disorders

 Defining Feature
 Marked pain during intercourse
 10. Dyspareunia
 From Latin words meaning “painful mating”
 Persistent or recurrent pain with attempted or
complete vaginal entry and/or penile vaginal
intercourse.
 Adequate sexual desire, arousal, and ability to attain
orgasm
 10% to 15% of women report pain during intercourse
VVS – inflammation of the vulvar vestibule (yellow arrows)

minimizing the vaginal opening causing pain on
intromission.
Sexual Pain Disorders

 10. Dyspareunia
 Etiology
Injury during childbirth, scars of episiotomy, penis
hitting on remnants of hymen, wiry pubic hair, pelvic
diseases, and/ or allergic reactions to:
Vaginal douches
Contraceptives
Protein in male semen
Psychological causes are rare
Sexual Pain Disorders: An Overview (cont.)

 11. Vaginismus
 Limited to females
 Persistent or recurrent difficulties to allow vaginal
entry of a penis, finger, and/or any object, despite
the woman’s expressed wish to do so. Often phobic
avoidance and anticipation of pain.
 Outer third of the vagina undergoes involuntary
spasms
 Complaints include feeling of ripping, burning, or
tearing
 Affects over 1-6% of women
 Prevalence rates are higher in more conservative
groups
 PC Muscle group (dark 8 figure) contracts during

vaginismus

 11. Vaginismus
 Etiology
Conditioned fear response, set off by anticipating
the vaginal penetration will be painful and
damaging
Fear is the result of anxiety and ignorance,
exaggerated stories of pain, trauma caused by an
earlier unskilled lover, and or trauma of childhood
sexual abuse
Assessing Sexual Behavior and Sexual Dysfunction
 Comprehensive Interview
 History of sexual behavior, lifestyle, and associated
factors
 Medical Examination
 Must rule out medical causes of sexual dysfunction
 Psycho-physiological Evaluation
 Exposure to erotic material
 Determine extent and pattern of sexual arousal
 Males – Penile strain gauge
 Females – Vaginal photoplethysmograph
Causes of Sexual Dysfunctions
 Biological Contributions
 Physical disease and medical illness
 Prescription medications
 Use and abuse of alcohol and other drugs
 Psychological Contributions
 The role of “anxiety” vs. “distraction”
 The nature and components of performance anxiety
 Psychological profiles associated with sexual dysfunction
 Social and Cultural Contributions
 Negative scripts about sexuality
 Learned negative attitudes about sexuality
 Negative or traumatic sexual experiences
 Poor interpersonal relationships, lack of communication
Figure 10.6 A model of functional and dysfunctional sexual arousal.

Psychosocial Treatment of Sexual Dysfunction
 Psychosexual Education alone

 Surprisingly effective
 Masters and Johnson’s Psychosocial Intervention
 Education
 Eliminate performance anxiety – Sensate focus
and non-demand pleasuring
 Additional Psychosocial Procedures
 Squeeze technique – Premature ejaculation
 Masturbatory training – Female orgasm disorder
 Use of dilators – Vaginismus
 Exposure to erotic material – Low sexual desire
problems
Assessment
 1. Medical, psychosocial, and psycho-physiological
evaluations
 2. Clinical interviews and self-report questionnaires
(individual and couple)
 *3 sessions in length*
1st session: Introductory Remarks
Time for questions, Interview one partner
Other partner fills out questionnaires
2nd session: “Has anything changed?”
3rd session: Assess interaction between partners
(problems/strengths in communication)
Assumptions
 Clients will:
- Be embarrassed
- Not understand medically correct
terminology
- Be misinformed about sexual
functioning
- Be in crisis
- Not have been open with one another about
sexual matters
Goals
 1. Establish rapport (make them comfortable)

 2. Obtain a general description of sexual problems
 3. Obtain a thorough psychosocial history
 4. Obtain a description of other life concerns and current

stressors
 5. Determine whether sex therapy is appropriate for the
couple at this time
Psychoeducation
 1. Anatomy (diagrams, models)

 2. Physiology
 3. Unrealistic expectations
 4. Myths about sexuality (hardest misconception to
dispel)
*Simple psycho-education may lead to rapid improvement

in the first few sessions
MYTHS OF MALE SEXUALITY

 1. Men should not have certain emotions
 2. In sex, it’s performance that counts.
 3. The man must take charge and orchestrate sex.
 4. A man always wants and is always ready to have sex.
 5. All physical contact must lead to sex.
 6. Sex equals intercourse.
 7. Sex requires and erection.
 8. Good sex is linear progression of excitement
terminated only by orgasm.
 9. Sex should be natural and spontaneous.
 10. In this enlightened age, myths 1-9 no longer have
any influence on us.
MYTHS OF FEMALE SEXUALITY

 1. Sex in only for women under 30.
 2. Normal women have an orgasm every time they have
sex.
 3. All women can have multiple orgasms.
 4. Pregnancy and delivery reduce women’s sexual
responsiveness.
 5. A woman’s sex life ends with menopause.
 6. There are different kinds of orgasm related to a
woman’s personality. Vaginal orgasms are more feminine
and mature than clitoral orgasms.
 7. a sexually responsive woman can always be turned
on by her partner.
MYTHS OF FEMALE SEXUALITY (cont)

 8. Nice women aren’t aroused by erotic books or films.
 9. you are frigid if you don’t like the more exotic forms of
sex.
 10. if you can’t have an orgasm quickly and easily,
there’s something wrong with you.
 11. Feminine women don’t initiate sex or become wild
and unrestrained during sex.
 12. You’re frigid if you don’t have sexual fantasies and a
wanton woman if you do.
 13. Contraception is a woman’s responsibility, and she’s
just making up excuses if she says contraceptive issues
are inhibiting her sexually.
Exploring Sexual Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 1. Hypoactive Sexual Desire and Sexual Aversion
 *Affectual awareness – visualizing sexual scenes to
uncover negative emotions about sex
 *Cognitive self-instruction training – learn to
generate “coping statements”
 *Desire diary – record sexual thoughts and feelings,
read and view erotic media, fantasize
 *Pleasurable shared activities – strengthen feelings
of sensual enjoyment and sexual attraction
 *In cases of molest, mock letters/ dialogues are
made to express feelings

 • Sildenafil (Viagra)
 – 4 hour half-life: 1hr before planned sexual activity
 – Side effects: ~10% headache, flushing, dyspepsia,
nasal congestion, visual disturbances
 • Vardenafil (Levitra)
 – 1 hr before planned sexual activity: 4-6 hour half-
life
 • Tadalafil (Cialis)
 – 30 min before sexual activity: 17 hour half-life
 – Fewer side effects (no food absorption effect,
reduced


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Muscles relax allowing dilation and free blood flow


 *Yohimbine (bark of African yohimbe tree),
trazadone, apomorphine – involves
neurotransmitters
 *Penile prosthesis – surgical implantation of semirigid

rubber, wire, or silicon rods.
 *Topical creams
 *Inflatable prosthesis
 *Vascular surgery

 *Yohimbine (bark of African yohimbe tree),
trazadone, apomorphine – involves
neurotransmitters
 *Penile prosthesis – surgical implantation of semirigid
rubber, wire, or silicon rods.
 *Topical creams – uncertain efficacy
 *Inflatable prosthesis
 *Vascular surgery – limited and short
 term benefit
*Tease technique added to Sensate Focus

 2. Male Erectile Disorder:Non-demand Sensate Focus
Stage 1
– Touch body (no genitals or breast) with goal
of increasing awareness
– Limited touching: Ignore arousal
Stage 2
– Touching all over
– “receiver” guides hand of “toucher”
Stage 3
– Mutual touching that feels natural
– Begin to shift attention away from own body
onto partner’s : Intercourse is still off limits
Subsequent stages
– Increase genital touching with goal of arousal
– Proceed to intercourse when ready

 3. Male Orgasmic Disorder
 - Non-demand sensate focus by Masters and Johnson
 The focus is on enhancing and sustaining pleasure, not
orgasm and performance
4. Premature Ejaculation
*Stop-start or pause or just pull-out-and-stop technique
- stimulation of penis stops just before he ejaculates;
arousal subsides
- intromission but no thrusting
- female creates thrusting with slow and long strokes

4. Premature Ejaculation

5. Female Arousal and Orgasm Dysfunctions
*Self-exploration and body awareness
*Directed masturbation training
- step-by-step manner how to masturbate effectively
and, eventually, how to reach orgasm during sexual
interactions
- includes diagrams and reading materials, self-
stimulation, erotic material and fantasies, role playing,
sensate focus, and positional training.
- 90% trainees learned to have an orgasm
*Straightforward assurance of their normality

5. Vaginismus
 *Relaxation technique – education on how to relax
muscles at the opening of the vagina, gradually using
dilators
 *gradual behavioral
 exposure
 6. Dyspareunia
 * In physical causes, scars or lessions, appropriate
intercourse positions can be taught avoiding injured area
 *Gynecological exam must be made as majority of cases
are undiagnosed physical problems.

6. Dyspareunia
SAMUEL H. AQUINO JR.

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Abnormal Psychology: An Integrative Approach, 4th Edition, David H.

Sexual and Gender Identity Disorders

“Despite a lifetime of service to the cause of

The Observer (London), "Sayings of the Week"

Sexual Dysfunctions: An Overview

Figure 10.3 The human sexual response cycle.

Sexual Desire Disorders

 1. Hypoactive Sexual Desire Disorder

Sexual Desire Disorders

 2. Sexual Aversion Disorder

 Hypoactive Sexual Desire Disorder and Sexual

- Socio-culturaland Psychological causes

Sexual Arousal Disorders

 4. Male Erectile Disorder

 4. Male Erectile Disorder (cont)

- Socio-cultural and Psychological causes

Sexual Arousal Disorders

 5. Female Sexual Arousal Disorder

Sexual Arousal Disorders

 • Occasionally relieved by orgasm

Orgasm Disorders: An Overview

Orgasm Disorders: An Overview

Orgasm Disorders: An Overview

 Retrograde ejaculation is the least

Sexual Pain Disorders

VVS – inflammation of the vulvar vestibule (yellow arrows)

Sexual Pain Disorders

Sexual Pain Disorders: An Overview (cont.)

Sexual Pain Disorders: An Overview (cont.)

 PC Muscle group (dark 8 figure) contracts during

Sexual Pain Disorders: An Overview (cont.)

Assessing Sexual Behavior and Sexual Dysfunction

Causes of Sexual Dysfunctions

Figure 10.6 A model of functional and dysfunctional sexual arousal.

Psychosocial Treatment of Sexual Dysfunction

 Psychosexual Education alone

 1. Establish rapport (make them comfortable)

 4. Obtain a description of other life concerns and current

 1. Anatomy (diagrams, models)

*Simple psycho-education may lead to rapid improvement

MYTHS OF MALE SEXUALITY

MYTHS OF FEMALE SEXUALITY

MYTHS OF FEMALE SEXUALITY (cont)

Exploring Sexual Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

EID Kit (free lubricant) for $80 only!

TREATMENT OF SEXUAL DYSFUNCTIONS

Muscles relax allowing dilation and free blood flow

TREATMENT OF SEXUAL DYSFUNCTIONS

 *Penile prosthesis – surgical implantation of semirigid

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

TREATMENT OF SEXUAL DYSFUNCTIONS

SAMUEL H. AQUINO JR.

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