1. Sexual & Gender Identity Disorders Not Sexual Abuse - Child or Adult Nor Relational Problems

2. Disorders Sexual Dysfunctions Paraphilias Gender Identity Disorders

3. Sexuality A most uncomfortable topic  for beginning counselors Next to death  the most shunned topic in society Males  Less likely to discuss sexual problems Females  Less likely to recognize problems

4. Sexual Dysfunctions Typified by inhibitions  in appetite or psychophysiological changes characterizing sexual response cycle  Must cause marked distress or interpersonal difficulty  Must be both recurrent & persistent, although some dysfunctions may be short-lived or episodic  Divided as related to Sexual desire Sexual arousal Orgasm Sexual pain

5. Diagnosis of Sexual Dysfunction Depends on  Extent to which it troubles client  Clinician's judgment  Adequacy of sexual stimulation Sometimes multiple sexual dysfunctions diagnosable Desire, arousal, & orgasm problems  correspond to 3 phases of 4 in sexual response cycle Appetitive/desire Excitement Orgasm Resolution

6. Sexual Disorders Hypoactive Sexual Desire disorder Sexual Aversion disorder Sexual Arousal disorders  Female Sexual Arousal Disorder  Male Erectile disorder Orgasmic disorder  Female Orgasmic Disorder  Male Orgasmic Disorder  Premature Ejaculation Disorder

7. More Sexual Disorders Sexual pain disorders Dyspareunia (Not due to GMC) Recurrent or persistent genital pain associated with sexual intercourse Either male or female Not caused exclusively by Vaginismus or lack of lubrication Associated with marital disturbance & avoidance of sexual situations  Vaginismus (not to GMC)—involuntary spasm of muscles  May include some secual function but not intromission  Could involve past traumaa  Or young age  Could also happen with other insertions, tampon, etc. Sexual Dysfunction due to GMC Substance-Induced Sexual Dysfunction Sexual Dsyfunction NOS

8. Subtypes & Associated Features Lifelong vs acquired Generalized versus situational Due to psychological factors vs to combined factors Often occur  with or focus on interpersonal relationship problems  With depression, anxiety, or somatic symptoms  Anxiety & excessively high subjective standards for performance

9. Age & Cultural Factors Advancing age may equal decreased functioning Family values & stereotypes may play a role If Axis I Dx primary cause of sexual problems, do not diagnosis sexual dysfunction Negative attitudes toward sexuality  Past experiences  Internal conflicts  Inadequate education  Rigid cultural values  Severe mental disorders

10. Treatment Need extensive training; FL licensing law Ethics presents referral to expert Sexual therapists highly trained & know ethics Not uncommon to see more than 1 therapist Higher rate of success for some sexual & especially sexual pain disorders Concept of accepting responsibility to make changes (Adlerian theory) Behavior modification, psychotherapy & medication from Masters & Johnson early work Meds  Anti-anxiety agents  Tricyclic antidepressants to prolong sexual response for premature ejaculation  Meds to Improve sexual desire  VIAGRA & others… what must be present  Testosterone to affect libido for low sexual desire

11. Paraphilias Conditions in which sexual instincts are expressed  socially prohibited  unacceptable or  biologically undesirable Sexual arousal is  In response to sexual objects or situations  not part of normative arousal-activity patterns Essential – unusual or bizarre imagery or acts necessary fro arousal

12. Pharaphilias acts Involve: Preference for nonhuman objects Repetitive activity  with humans involving real or simulated suffering or humiliation  with nonconsenting partners, statistically male-related & may have legal significance Impairment to being involved in reciprocal affectionate relationships Psychosexual dysfunctions common Often antisocial people  if behavior is destructive & exploitive Virtually all reported cases (except S&M) are males

13. Pharaphilias – Needed to achieve sexual excitement Exhibitionism  repetitive act of exposing genitals to unsuspecting stranger Fetishism  preferred or exclusive use of nonliving objects Frotteurism  involves touching & rubbing nonconsenting person Pedophilia  recurrent, intense, sexual urges & sexually arousing fantasies  Involves sexual activity with prepubescent child Zoophilia  use of animals Necrophilia  intercourse with the dead

14. More Paraphilias Sexual Sadism  sexually aroused through infliction of physical or psychological suffering on another person  Must prevail Either inflicting suffering on nonconsenting partner OR With consenting partner, but use of humiliation or mild injury Or Body injure extensive, permanent, or possibly mortal on consenting partner Sexual Masochism – preferred mode  beaten, humiliated, bound, or made to suffer; often participates intentionally in physical harm or life threats Transvestic Fetishis  involves cross dressing Voyeurism  repeated viewing of unsuspected people who are naked, disrobing, or engaging in sexual activity  Enjoy thinking of observed as helpless & humiliated if known seen  Visual types who may not go beyond showing & looking

15. Treatment of Paraphilias Treatment sought due to negative consequences Difficult to treat  Lack of dysphoria  High physical gratification Prognosis depends on  Age of onset  Frequency  Concurrent substance abuse  Feelings of guilt or shame  Outlook best if normal intercourse experienced in past  Outlook good if high motivation to change Treatment success rates low Psychotherapy alone not usually productive  Medication & therapy together Must be therapeutic not punitive Many behavior therapies Cognitive on faulty beliefs  Interpretation of child’s docility as desire Relaxation training Group therapy Virtually no literature

16. Gender Identity Disorders Characterized by feelings of discomfort  about anatomic sex  Not same as transvestite Code based on current age Sufficiently strong & persistent cross- gender identification  that one desires to be, or believes one should be, a member of opposite sex

17. GID Clinically significant distress or impairment in social/occupational Feeling of discomfort or inappropriateness with current sex or sex role In children  strong preference for behaviors & activities related to opposite sex while avoiding those of own sex  What about tomboys? Others? Adults function in opposite- sex role whenever possible & often alter bodies  Hormonal treatment  Surgery Including genital-change procedures Specify if: (for sexually mature individuals)  Sexually attracted to males  Sexually attracted to females  Sexually attracted to both  Sexually attracted to neither

18. Other features Associated features  Social problems or ostracism, often begun in childhood  Males sometimes have childhood memories of parent encouraging “cute” dressing & mimicking female mannerisms Course  Most children not continue all criteria as adults  Although 75% describe homo/bisexual gender preference in late adolescence or adulthood Differential Diagnosis  Change in sex solely for perceived social/cultural advantage & nonconformity  Chromosomal or congenital abnormality not diagnosed here  No psychotic symptoms to support  Some men meet both GID & Transvestic Fetishism could be comorbid yet most do not meet TF