1. Sexual Dysfunctions and Gender Disorders and Gender Disorders Presentation By: Leo Cruz, Clinical Therapist Family Practice Medicine August 23, 2004 August 23, 2004

2. 2 DSM-IV: Sexual Aversion Disorder DSM-IV: Sexual Aversion Disorder Individuals with this sexual dysfunction order experiences absent or markedly diminished sexual appetite separate from any other mental disorder. Diagnostic criteria for 302.79 Sexual Aversion Disorder (cautionary statement A.Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual partner. B. The disturbance caused marked distress or interpersonal difficulty. C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction). Specify type: Lifelong Type Acquired Type Specify type: Generalized Type Situational Type Specify: Due to Psychological Factors Due to Combined Factor

3. 3 DSM-IV: Female Sexual Arousal Disorder DSM-IV: Female Sexual Arousal Disorder Women with this sexual dysfunction disorder experience inability to achieve or maintain an adequate “lubrication-swelling response of sexual excitement”. “lubrication-swelling response of sexual excitement”. Diagnostic criteria for 302.72 Female Sexual Arousal Disorder (cautionary statement) 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 (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

4. 4 DSM-IV: Male Erectile Disorder DSM-IV: Male Erectile Disorder Men with this sexual dysfunction disorder experience inability to achieve or maintain an adequate erection. Diagnostic criteria for 302.72 Male Erectile Disorder (cautionary statement) A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection. B. The disturbance causes 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 (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 Also: impotence Impotence Resource Center

5. 5 DSM-IV: Female Orgasmic Disorder DSM-IV: Female Orgasmic Disorder Women with this sexual dysfunction disorder experience delay in or absence of sexual orgasm. Diagnostic criteria for 302.73 Female Orgasmic Disorder (cautionary statement) 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 (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 Also: Inhibited Female Orgasm

6. 6 DSM-IV: Male Orgasmic Disorder DSM-IV: Male Orgasmic Disorder Men with this sexual dysfunction disorder experience delay in or absence of sexual orgasm. Diagnostic criteria for 302.74 Male Orgasmic Disorder (cautionary statement) 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 (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 Also: Inhibited Male Orgasm

7. 7 DSM-IV & DSM-IV-TR: Premature Ejaculation DSM-IV & DSM-IV-TR: Premature Ejaculation Men with this sexual dysfunction disorder experience orgasm with ejaculation before, immediately upon, or shortly after penetration and earlier than they expect it. Diagnostic criteria for 302.75 Premature Ejaculation (cautionary statement) 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 (e.g., withdrawal from opioids. Specify type: Lifelong Type Acquired Type Specify type: Generalized Type Situational Type Specify: Due to Psychological Factors Due to Combined Factors

8. 8 DSM-IV: Dyspareunia Men and women with this sexual dysfunction disorder experience otherwise unexplained genital pain before, during or after intercourse. Diagnostic criteria for 302.76 Dyspareunia 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 (e.g., a drug of abuse, a medication) or a general medical condition. Due to Combined Factors. Specify type: Lifelong Type Acquired Type Specify type: Generalized Type Situational Type Specify: Due to Psychological Factors Due to Combined Factors

9. 9 DSM-IV: Vaginismus Women with this sexual dysfunction disorder experience otherwise unexplained recurrent or persistent involuntary contraction of the perineal muscles around the outer third of the vagina associated with involuntary contraction of the perineal muscles around the outer third of the vagina associated with penetration with any object. Diagnostic criteria for 306.51 Vaginismus (cautionary statement) 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 (e.g., Somatization Disorder) and is not due exclusively to the direct physiological effects of 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

10. 10 DSM-IV Sexual Dysfunction Due to a General Medical Condition When there is evidence that a general medical condition is the exclusive physiologic cause of sexual dysfunction this diagnosis may be appropriate. Subtype is chosen according to similarity to the primary disorders and include: Female Dyspareunia l Female Hypoactive Sexual Desire Disorder l Male Erectile Disorder l Male Dyspareunia l Other Female Sexual Dysfunction l Other Male Sexual Dysfunction l Substance-Induced Dysfunction Diagnostic criteria for Sexual Dysfunction Due to…[Indicate the General Diagnostic criteria for Sexual Dysfunction Due to…[Indicate the General Medical Condition] Medical Condition] (cautionary statement) A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by the direct physiological effects of a general medical condition. C. The disturbance is not better accounted for by another mental disorder (e.g., Major Depressive Disorder).

11. 11 Select Code and term based on the predominate sexual dysfunction: 625.8 Female Hypoactive Sexual Desire Disorder Due to…[Indicate the General Medical Condition]: if deficient or absent sexual desire is the predominate feature 608.89 Male Hypoactive Sexual Desire Disorder Due to…[Indicate the General Medical Condition]: if deficient or absent sexual desire is the predominate feature. 607.84 Male Erectile Disorder Due to…[Indicate the General Medical Condition]: if male erectile dysfunction is the predominate feature 625.0 Female Dyspareunia Due to…[Indicate the General Medical Condition]: if pain associated with intercourse is the predominate feature 608.89 Male Dyspareunia Due to…[Indicate the General Medical Condition]: if pain associated with intercourse is the predominate feature 625.8 Other Female Sexual Dysfunction Due to…[Indicate the General Medical Condition]: if some other feature is predominate (e.g., Orgasmic Disorder) or no feature predominates 608.89 Other Male Dysfunction Due to…[Indicate the General Medical Condition]: if some other feature is predominate (e.g., Orgasmic Disorder) or no feature predominates 11Coding note: Include the name of the general medical condition on Axis I, e.g., 607.84 Male Erectile Disorder Due to Diabetes Mellitus; also code the general medical condition on Axis III (see Appendix G for codes).

12. 12 DSM-IV: Substance-Induced Sexual Dysfunction When there is evidence that use of alcohol or other drugs directly causes Sexual Dysfunction in excess of what would normally be expected from intoxication, and involving desire, arousal, orgasm or pain, diagnosis of the Substance Related Disorder may be appropriate. Diagnostic criteria for Substance-Induced Sexual Dysfunction cautionary statement) A. Clinically significant sexual dysfunction that results in marked distress or interpersonal difficulty predominates in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings that the sexual dysfunction is fully explained by substance use as manifested by either (1) or (2): (1)the symptoms in Criterion A developed during, or within a month of, Substance intoxication (2) medication use is etiologically related to the disturbance

13. 13 C. The disturbance is not better accounted for by a Sexual Dysfunction that is not substance induced. Evidenced that the symptoms are better accounted for by a Sexual Dysfunction that is not substance inducted might include the following: the symptoms precede the onset of the substance use or Dependence (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non- substance-induced Sexual Dysfunction (e.g., a history or recurrent non-substance-related episodes). Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication only when the sexual dysfunction is in excess of that usually associated with the intoxication syndrome and when the dysfunction is sufficiently severe to warrant independent clinical attention.

14. 14 Code [Specific Substance]-Induced Sexual Dysfunction: (291.8 (new code as of 10/01/96;; 291.89) Alcohol; 292.89 Amphetamine [or Amphetamine-Like Substance]; 292.89 Cocaine, 292.89 Opioid; 292.89 Sedative, Hypnotic, or Anxiolytic; 292.89 Other [or Unknown] Substance) Specify if: With Impaired Desire With Impaired Arousal With Impaired Orgasm With Sexual Pain Specify if: With Onset During Intoxication: if the criteria are met for intoxication with the substance and the symptoms develop during the intoxication syndrome

15. 15 DSM-IV & DSM-IV-TR: Fetishism This paraphilia is characterized by sexual fantasies, urges, or behaviors involving use of non-human objects to produce or enhance sexual arousal with or in the absence of a partner. Diagnostic criteria for 302.81 Fetishism (cautionary statement) A. Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the use of non-living 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. C. The fetish objects are not limited to articles of female clothing used in cross- dressing (as in Transvestic Fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator).

16. 16 DSMIV: Transvestic Fetishism Heterosexual males with this paraphilia dress in female clothes (cross-dress) to produce or enhance sexual arousal, usually without a real partner, but with the fantasy that they are the female partner as well. Diagnostic criteria for 302.3 Transvestic Fetishism (cautionary statement) A. Over a period of at least six months, in a heterosexual male, 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. Specify if: With Gender Dysphoria: if the person has persistent discomfort with gender role or identity Also: cross dress, cross-dress, transvestite

17. 17 DSM-IV-TR: Sexual Sadism Individuals with this Paraphilia use sexual fantasies, urges, or behaviors involving infliction of pain, suffering or humiliation to enhance or achieve sexual excitement. Diagnostic criteria for 302.84 Sexual Sadism (cautionary statement) A. Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person. B. The person has acted on these urges with a non-consenting person, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. Also: sadist, sadomasochism, Marquis de Sade, masochism

18. 18 DSM-IV: Sexual Masochism Individuals with this paraphilia use sexual fantasies, urges, or behaviors involving being beaten, humiliated, bound or tortured to enhance or achieve sexual excitement. Diagnostic criteria for 302.83 Sexual Masochism Diagnostic criteria for 302.83 Sexual Masochism (cautionary statement) A. Over a period of at least six 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. Also: masochist, sadomasochism, Sadism

19. 19 DSM-IV-TR: Frotteurism This Paraphilia is characterized by sexual fantasies, urges, or behaviors involving touching or rubbing one’s genitals against the body of a non-consenting person. Diagnostic criteria for 302.89 Frotteurism (cautionary statement) A. Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a non-consenting person. B. The person has acted on these urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

20. 20 DSM-IV-TR: Voyeurism This Paraphilia is characterized by sexual fantasies, urges, or behaviors involving observing an unknown and non-consenting person, usually unclothed and/or engaged in sexual activity, to produce sexual excitement. Diagnostic criteria for 302.82 Voyeurism (cautionary statement) A. Over a period of at least six months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. B. The person has acted on these urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty. C. Also: Voyeur

21. 21 DSM-IV-TR: Pedophilia This Paraphilia is characterized by sexual activity with a child, usually age 13 or younger, or in the case of an adolescent, a child five years younger than the pedophile. Diagnostic criteria for 302.2 Pedophilia (cautionary statement) A. Over a period of at least six 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 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 five years older than the child or children in Criterion A.

22. 22 Note: Do not include an individual in late adolescence involved in an ongoing sexual relationship with a 12 or 13-year old. Specify if: Sexually Attracted to Males Sexually Attracted to Females Sexually Attracted to Both Specify if: Limited to Incest Specify type: Exclusive Type (attracted only to children) Nonexclusive Type

23. 23 DSM-IV-TR: Exhibitionism This Paraphilia is characterized by sexual fantasies, urges, or behaviors involving surprise exposure of the individual’s genitals to a stranger. the individual’s genitals to a stranger. Diagnostic criteria for 302.4 Exhibitionism (cautionary statement) A. Over a period of at least six 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 urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.

24. 24 DSM-IV & DSM-IV-TR: Gender Identity Disorder Individuals with this mental disorder are uncomfortable with their apparent or assigned gender and demonstrate persistent identification with the opposite sex. Diagnostic criteria for Gender Identity Disorder (cautionary statement) A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following: (1)repeatedly stated desire to be, or insistence that he or she is, the other sex (2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing (3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex (4)intense desire to participate in the stereotypical pastimes of the other sex (5)strong preference for playmates of the other sex. In adolescents and adults, the disturbance is manifested by symptoms such as a sated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

25. 25 B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born with the wrong sex. C. The disturbance is not concurrent with a physical intersex condition.

26. 26 D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Code based on current age: 302.6 Gender Identity Disorder in Children 302.85 Gender Identity Disorder in Adolescents or Adults Specify if (for sexually mature individuals): Sexually Attracted to Males Sexually Attracted to Females Sexually Attracted to Both Sexually Attracted to Neither All prior information reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, fourth Edition, Copyright 1994 American Psychiatric Association

27. 27 Gender Identity Disorders and the Paraphilias

28. 28 Factors predictive of favorable post-surgery adjustment  Emotional stability  Successful adaptation to a new role for one year  Understanding of surgical limitations and consequences  Gender identity program psychotherapy

29. 29 (in DSM-IV)  Gender Identity Disorders: You have the sexual anatomy of a male but inside you feel like a female (or vice versa)  Paraphilias: You feel like the man or woman that you are but your sexual preference is socially unacceptable or illegal.  Sexual Dysfunctions: You feel like the man or woman that you are and your sexual preference is socially acceptable but you aren’t enjoying it.

30. 30 The Paraphilias  Paedophilia: Sexual activity with a prepubescent child by someone who is at least 16 and at least five years older than the child.

31. 31 Four-factor Theory of Cause of Paedophilia… Individual level of Societal level of explanationexplanation III. Blockage Inadequate socialRepressive norms skills; maritalabout masturbation, disturbanceextramarital sex IV.Disinhibition e.g., AlcoholismCultural tolerance

32. 32 The Paraphilias…  Voyeruism: Sexual arousal from watching another person naked without their knowledge.  Sexual Sadism and Sexual Masochism: Sexual arousal from watching another person suffer or from being made to suffer.  Fetishism: Sexual arousal from use of non- living objects.

33. 33 Four-factor Theory of Cause of Paedophilia Individual level Societal level of of explanationexplanation I. Emotional Congruence I. Emotional Congruence ArrestedMale need for development, dominance Low self-esteem II. Sexual Arousal Arousing child-Child pornography hood experience

34. 34 The Paraphilias…  Exhibitionism: Sexual arousal from exposing one’s genitals to a stranger.

35. 35 The Paraphilias…  Transvestic Fetishism: Sexual arousal from cross-dressing  Frotteurism: Sexual arousal from rubbing against a non-consenting person.  Paraphilia Not Otherwise Specified

36. 36 Treatment of the Paraphilias Lessening the arousal value of deviant sexual stimuli:  Aversion (learning) - Electrical aversion - Foul smell aversion - Covert sensitization - Shame therapy  Masturbatory extinction (learning)  Biofeedback (learning)

37. 37  Castration (biological) Increasing the arousal value of appropriate sexual stimuli:  Orgasmic reorientation (learning

38. 38 Treatment of the Paraphilias… Lessening the anxiety associated with appropriate sexual behaviors:  Social skills training, e.g., assertiveness training (learning)  Systematic desensitization (learning)

39. 39 Ancillary Procedures  Empathy training for rapists and exhibitionists (cognitive)  Family therapy for incest (cognitive)  Marital therapy (cognitive)  Group therapy (cognitive)

40. 40 TABLE 2 Preventative Sexual Health Questions ______________________ ______________________ How do you protect yourself from HIV and other STDs? HIV and other STDs? Have you ever been tested for HIV? Would you like to be? Do you use anything to prevent Pregnancy? Are you satisfied with that method? Have you ever been immunized Against hepatitis? Would you like to be? ______________________ ______________________ HIV = human immunodeficiency virus STDs = sexually transmitted diseases Information from Annon JS. The Behavioral Treatment of Sexual Problems. Honolulu: Enabling Systems, 1974-1975. TABLE 3 P.L.I.S.S.I.T. Model for Approaching Sexual Health Problems ______________________ ______________________ Permission: (1) For physician to discuss sex with the patient; (2) discuss sex with the patient; (2) for patient to discuss sexual for patient to discuss sexual concerns now or in the future; and concerns now or in the future; and (3) to continue normal (i.e., not (3) to continue normal (i.e., not potentially harmful) sexual potentially harmful) sexual behaviors. behaviors. Limited Information: Clarify misinformation, dispel myths, and misinformation, dispel myths, and Provide factual information in a Limited manner. Specific Suggestions: Provide specific suggestions directly specific suggestions directly related to the particular problem. related to the particular problem. Intensive Treatment: Provide highly individualized therapy for more complex issues. more complex issues.

41. 41 Screening for Sexual Health History Have you been sexually involved with anyone in the past six months? _______________________________________________ Yes No Yes NoYes With men, women Have you ever been sexually involved With men, women Have you ever been sexually involved or both? with anyone? or both? with anyone? What sexual concerns do you What sexual concerns do you (or your partner(s)) have? (or your partner(s)) have? If you were sexually active, do you If you were sexually active, do you imagine it would be with men, women, or both? What are your concerns or questions What are your concerns or questions about sex? Figure 1. Algorithm for screening patients for sexual history.

42. 42 Table 1 Questions for a Detailed Sexual History:  Are you currently sexually active? Have you ever been?  Are your partners men, women, or both?  How many partners have you had in the past month? Six months? Lifetime?  How satisfied with your (and/or your partner’s) sexual functioning are you?  Has there been any change in your (or your partner’s) sexual desire or the frequency of sexual activity?  Do you have, or have you ever had, any risk factors for HIV? (List blood transfusions, needle stick injuries, IV drug use, STD’s, partners who may have placed you at risk.)

43. 43 Questions Cont.  Have you ever had any sexually related diseases?  Have you ever been tested for HIV? Would you like to be?  What do you do to protect yourself from contracting HIV?  What method do you use for contraception?  Are you trying to become pregnant (or father a child)?  Do you participate in oral sex? Anal sex?  Do you or your partner(s) use any particular devices or substances to enhance your sexual pleasure?

44. 44 Questions Cont.  Do you ever have pain with intercourse?  Women: Do you have any difficulty achieving orgasm?  Men: Do you have any difficulty obtaining and maintaining an erection?  Difficulty with ejaculation?  Do you have any questions or concerns about your sexual functioning?  Is there anything about your (or your partner’s) sexual activity (as individuals or as a couple) that you would like to change? ___________________________________________________ HIV= human immunodeficiency virus; IV= intravenous; STDs = sexually transmitted diseases