Sexual Disorders PDF

Unit 5 Sexual Disorders and
Gender Dysphoria*
Structure
5.0 Objectives
5.1 Introduction
5.2 What is Normal Sexuality?
5.3 Sexual Response Cycle
5.4 Sexual Disorders
5.4.1 Male Hypoactive Sexual Desire Disorder
5.4.2 Erectile Disorder
5.4.3 Premature (Early) Ejaculation Disorder
5.4.4 Delayed Ejaculation Disorder
5.4.5 Female Sexual Interest/Arousal Disorder
5.4.6 Genito-Pelvic Pain/Penetration Disorder
5.4.7 Female Orgasmic Disorder
5.5 Gender Dysphoria
5.5.1 Gender Dysphoria in Childhood
5.5.2 Transsexualism
5.6 Let Us Sum Up
5.7 References
5.8 Key Words
5.9 Answers to Check Your Progress
5.10 Unit End Questions
5.11 Web Resources
5.0 OBJECTiVES
After reading this Unit, you will be able to:
●● make an attempt to define boundaries between normality and
psychopathology in understanding sexuality;
●● explain sexual response cycle of men and women;
●● explain sexual dysfunctions and paraphilias; and
●● develop an understanding of the treatment approaches of sexual
disorders and dysfunctions.
5.1 INTRODUCTION
Academic Counsellor Dr. Mahima was discussing about various disorders
with the learners. Let us look at their conversation:
*Ms. Vrushali Pathak, Assistant Professor of Psychology (Ad-hoc), Jesus and Mary
College, University of Delhi, New Delhi
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Dr. Mahima: Hello learners. Sexual Disorders and Gender
Dysphoria
Learners: Hello Maam.
Dr. Mahima: In the first block of BPCC113, we looked at various
psychological disorders. Can any one tell me about them with their brief
explanation?
Seema (Learner): Maam, we discussed first about schizophrenia and it
can be explained as a broad spectrum of condition that affects individual’s
cognitive and emotional functioning including delusions and hallucinations,
disorganised speech, behaviour and inappropriate emotions.
Manmeet (learner): The other disorder that we studied was mood disorders.
Mood disorders are serious changes in one’s mood that may lead to distress
and dysfunction. Mood disorders are classified as unipolar and bipolar
disorder. Bipolar disorder was earlier known as manic-depression.
Janet (learner): And Maam we also studied about personality disorders. In
simple terms, personality disorders are a heterogeneous group of disorders.
and are characterised by problems in forming a stable positive sense of self
and sustaining close and constructive relationships.
Amir (Learner): To add to what Janet explained about personality
disorders. According to DSM-5, an individual is diagnosed with personality
disorder if there is significant impairment in self (identity or self-direction)
and interpersonal (intimacy or empathy) functioning.
Seema (Learner): Also Maam, DSM-5 categorises personality disorders
three clusters on the basis of important similarities amongst the disorders,
namely cluster A, B and C.
Dr. Mahima was very happy listening to all her learner.
Dr. Mahima: Did we miss a disorder?
Sameer (Learner): Maam, there is also Substance use disorder. Substance
use disorder involves ingestion of psychoactive substances in excessive
quantity, there may be a need to cut down on the usage but the person
finds it difficult to do so. In DSM-5, the substance use disorder is stated as
Substance- related and Addictive Disorders.
Dr. Mahima: I am very happy that all of you have been revising and taking
great interest in this course. Well we have one more disorder to study and
that is what has been covered in the Unit 5 of BPCC113 .
Seema (learner): Which disorder is this Maam?
Dr. Mahima: Sexual Disorders and Gender Dysphoria. Sexual disorders
can be discussed in terms of sexual dysfunction. Sexual dysfunction refers
to impairment in the desire or ability to achieve sexual pleasure and
gratification. As per DSM-5, Gender Dysphoria mainly relates to Gender
Identity Disorder.
We really hope that like the learners above, you have also been revising and
learning about various disorders. In the present unit we will cover sexual
disorders and gender dysphoria
Humans have sexual preferences and fantasies which may be surprising for
others and even for oneself at times. Sexuality is considered to be one of
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Mental Disorders- II the most private aspects of life which may contribute to love, happiness and
pleasure. Sex is an important concern for various people, but many have
difficulty talking about it openly as sex is considered as a taboo in various
societies and cultures.
Thus, in the present unit, we will attempt to define boundaries between
normality and psychopathology in understanding sexuality. We will also
describe the influence of culture and gender on sexual norms. We will
explain sexual response cycle of men and women. Sexual dysfunctions
and paraphilias will also be explained. We will finally try to develop
an understanding of the treatment approaches of sexual disorders and
dysfunctions.
Box 5.1 Some important terms to remember: Sex:
Sex Quality of being male or female.
Sexual intercourse: Insertion of penis when erect in vagina. Other forms
include anal sex (penetration of the anus by the penis), oral sex (penetration
of the mouth by the penis or oral penetration of the female genitalia) and
fingering (sexual penetration by the fingers).
Sexuality: Encompasses sex, gender identities, roles, sexual orientation,
pleasure, intimacy and reproduction.
Sexual health: “The integration of somatic, emotional, intellectual &
social aspects of sexual being in ways that are positively enriching and
enhance personality, communication and love” (WHO, 2002).
Sexual rights: Rights free of coercion, discrimination and violence.
Sexual norm: It could be a personal or social norm. Culture having a norm
regarding sexuality and defining it on the basis of age, consanguinity, race.
5.2 WHAT IS NORMAL SEXUALITY?

Definition of normal or desirable human sexual behaviour may vary with
time and place. For instance, Von Krafft-Ebing (1902) claimed that early
masturbation would damage the sexual organs and would lead to the
exhaustion of a finite reservoir of sexual energy. Victorian view was that
too much sexual activity and sexual appetite was dangerous and thus had
to be restrained using various ways. Current views seem to be very tolerant
of a variety of sexual expressions. It is only when these fantasies begin to
affect other people and harm them, they begin to qualify as abnormal. If the
sexual fulfilment becomes difficult or socially unacceptable then that would
be considered as abnormal. Three kinds of sexual behaviour meet this
definition; first, gender identity disorder, psychological dissatisfaction with
the biological sex of himself/herself. This disorder may not be specifically
sexual in nature, rather a disturbance in the person’s identity as either a
male or female (the traditional binary distinction). Second, difficulties in
functioning adequately while having sex are categorised under various
sexual dysfunctions. And, third, is a category named paraphilias, a term for
sexual deviation. It includes deviances in which sexual arousal occurs in the
context of inappropriate objects or individual. But, before understanding
these disorders, it is important to revisit the question – what qualifies as
normal sexual behaviour?
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One way to understand normality has been to understand the norm or what is Sexual Disorders and Gender
prevalent in the society, although it may not be necessarily the most correct Dysphoria
or accurate way to go about it. In a survey conducted by Billy, Tanfer, Grady
and Klepinger (1993), 3,321 males were interviewed (in the age bracket
of 20-39 in United States). All participants in the study were sexually
experienced, at least in the vaginal intercourse. Three-fourth participants in
the study were engaged in oral sex, but only one-fifth had ever participated
in anal sex. Another finding of the research was that almost 23.3 percent
of the sample had sex with twenty or more partners which is considered as
the high-risk behaviour. More than 70 percent were found to have only one
sexual partner during the previous year. One of the surprising findings from
this research was that majority of the men had engaged only in heterosexual
behaviour and only 2.3 percent had engaged in both homosexual as well
as heterosexual behaviour, whereas only 1.1 percent had engaged in
homosexual behaviour exclusively.
5.3 SEXUAL RESPONSE CYCLE

Many researchers have tried understanding the sexual response cycle, but
the Kinsey group (in 1940s) made a breakthrough attempt by interviewing
people about their sexuality (Kinsey, Pomeroy, & Martin, 1948). Masters
and Johnson went a step ahead by collecting laboratory data in order to study
physiology and psychology of sexual behaviour. They have contributed
two major books to the field- Human Sexual Responses (1966) and Human
Sexual Inadequacy (1970).
Phases in human sexual response cycle:
1) Desire phase: Sexual urges occur as a response to the sexual cues or
fantasies.
2) Arousal phase: This stage is like the preparation for main event and
involves foreplay as well. An increase in muscular tension, breathing
and heart rate can be noticed. In males, penile tumescence (increased
flow of blood into penis) and erection can be observed. In females,
vasocongestion (blood pools in the pelvic region) can be observed
leading to vaginal lubrication and breast tumescence (erect nipples).
3) Plateau phase: In this stage, the changes noticed in the arousal phase
are intensified. Genitalia may become highly sensitive (may be painful
to touch). Muscle spasm can be noticed in the feet, hands and face.
4) Orgasm phase: This is the climax of the sexual response cycle
that involves involuntary muscle contraction. There is rapid intake
of oxygen followed by sudden, forceful release of sexual tension.
In males, there is feeling of inevitability of ejaculation followed by
ejaculation of semen and in females, rhythmic contractions in vagina
occurs.
5) Resolution phase: This stage is marked by decrease in arousal
followed by orgasm (especially in males). It is marked by a general
sense of well-being, enhanced intimacy and fatigue. With further
sexual stimulation,females are capable of returning to orgasm phase
(multiple orgasms in females) but males need more time to recover
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Mental Disorders- II after the orgasm and this period is known as the refractory period
which may last from several minutes to hours.
Fig. 5.1: The human sexual response

(Based on Masters, W. H., & Johnson, V. E. (1966). Human sexual
response. Boston: Little, Brown. And Kaplan, H. S. (1979).
Disorders of sexualdesire, New York, NY: Brunner)
Check Your Progress I
1) List the phases in human sexual response cycle.
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5.4 SEXUAL DISORDERS

Sexual disorders can be discussed in terms of sexual dysfunction. Sexual
dysfunction refers to impairment in the desire or ability to achieve sexual
pleasure and gratification. It can mainly be divided in 3 categories (as
proposed by DSM-5): those involving sexual desire and arousal; orgasmic
disorders and sexual pain disorders. Separate diagnostic criteria have been
provided for both men and women. Sexual dysfunction may occur in both
homosexual and heterosexual couples. It can be due to psychological or
interpersonal reasons or may have physical factors involved behind it. It
is also important to note that they might be a secondary consequence to
certain medications people may be taking (Baron-Kuhn & Segraves, 2007).
For sexual dysfunctions to be diagnosed it is important that the dysfunction
should be persistent and recurrent and should result in marked clinical
distress with functioning.
5.4.1 Male Hypoactive Sexual Desire Disorder
A person diagnosed with hypoactive sexual desire disorder has little or no
interest in any sexual activity and has been distressed due to low levels of
sexual thoughts and desires for at least 6 months. (Wincze, Bach, & Barlow,
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2008; Wincze, 2009). There are other ways to gauge it-if the frequency of Sexual Disorders and Gender
sexual activity is less than twice a month for a married couple, or if they do Dysphoria
not think about sex at all. There are men who may have sex twice a week but
just to keep their marriage safe and in reality, do not think about sex at all.
It is important to understand the possible factors that may be behind it before
the diagnosis is given- it could be due to some problems emanating from
partners, due to some cultural beliefs or even personal vulnerabilities or a
medical condition. Many experts have a belief that it is usually acquired or
situational rather than lifelong.
Treatment: It has been found that psychological factors are perhaps more
closely linked to low sexual desire in men in comparison to hormonal factors.
Thus, psychological treatment and therapies are more effective. For men
with low testosterone levels, testosterone injections are used (Brotto, 2010).
But still more research is required to understand the probable treatment
procedures of this disorder.
Box 4.2 DSM-5 Criteria for Male Hypoactive Sexual Desire
Disorder(APA, 2013)
A. Persistently or recurrently deficient (or absent) sexual/ erotic thoughts
or fantasies and desire for sexual activity. The judgment 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.
B. The symptoms in Criterion A have persisted for a minimum duration of
approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in the
individual.
D. 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 these effects of a substance/
medication or another medical condition.
5.4.2 Erectile Disorder
Erectile disorder is a sexual arousal disorder. Here, the issue is not sexual
desire. Individuals with arousal disorder may have sexual urges and a strong
desire to have sex but the problem is in becoming physically aroused. A
male with an inability to achieve or maintain erection sufficient enough for
sexual intercourse is diagnosed with the erectile disorder (Wincze, 2009).
It is diagnosed only when the difficulty has a psychogenic origin for a
combination of psychogenic and medical factors are involved.
Masters and Johnson (1975) hypothesised that anxiety about sexual
performance can lead to erectile dysfunction. Later, Barlow and colleagues
(1983, 1996) have questioned the role of anxiety as anxiety can also
enhance sexual performance. Barlow (2002) highlighted that the cognitive
distractions associated with anxiety in dysfunctional men may interfere
with sexual arousal. They may also get distracted by negative thoughts
about their performance during a previous sexual encounter. Thus, their
distraction and preoccupation with negative thoughts than anxiety has a
role to play here in inhibiting their sexual arousal (Wincze et al., 2008) and
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Mental Disorders- II further feeding on the self-defeating thoughts due to the inability to achieve
erection. For majority of men who take antidepressant medicines (SSRIs),
erectile dysfunction could be a side effect (Rosen & Martin, 2003). Increase
in age can also lead to erectile difficulties (Lindau, Schumm, Laumann,
Levinson, O’Muircheartaign& Waite, 2007). Most of the cases of erectile
dysfunction in older men can be due to vascular diseases due to which the
ability of the penis to hold blood decreases to maintain an erection. Thus,
hardening of the arteries, high blood pressure, and other diseases such as
diabetes that cause vascular problems often account for erectile disorder.
Smoking, obesity, and alcohol abuse are associated lifestyle factors, and
lifestyle changes can improve erectile function (Gupta et al., 2011).
Treatment: A number of medical treatment techniques are employed in
this case, especially when cognitive behavioural techniques fail. These
treatment techniques include: (1) medicines to promote erection (Viagra,
Levitra, Cialis); (2) injections of smooth-muscle-relaxing drugs onto
erection chambers; (3) a vacuum pump (Duterte, Seagraves & Althof, 2007).
In cases of nerve damage and thus inability to achieve erection, penile
implants are used. These are the devices made of silicone rubber which can
be inflated to provide erection on demand. The commercial success of drugs
like Viagra and Cialis is indicative of the prevalence of sexual dysfunction
in men and also the high importance people give to sexual performance.
Studies also reveal that of these medicines are used in conjunction with
cognitive- behavioural therapy, their effects can be enhanced (Meston &
Rellini, 2008).
Box 5.3: DSM-5 Criteria for Erectile Disorder (APA, 2013)
At least one of the three following symptoms must be experienced on
almost all or all (approximately 75–100 percent) occasions of sexual
activity (in identified situational contexts or, if generalized, in all contexts):
1) Marked difficulty in obtaining an erection during sexual activity.
2) Marked difficulty in maintaining an erection until the completion of
sexual activity.
3) Marked decrease in erectile rigidity.
B. The symptoms in Criterion A have persisted for a minimum duration
of approximately 6 months.
individual.
significant stressors and is not attributable to the effects of a substance/
5.4.3 Premature (Early) Ejaculation Disorder
“Premature ejaculation” of DSM-IV-TR is called as early ejaculation
disorder in DSM-5. Ejaculation may occur before, on, or very shortly after
penetration, much before the man wants it to. Studies have revealed that
the average duration of time to ejaculate with this disorder is almost 15
seconds. Very importantly, the major consequence of this disorder is failure
of the partner to achieve sexual satisfaction and also embarrassment for
the early ejaculating man. Due to early ejaculation both the sexual and
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interpersonal relationship of the individual with their partner gets impacted Sexual Disorders and Gender
negatively (Graziottin & Althof, 2011). As per DSM- 5, a number of factors Dysphoria
might impact the time of ejaculation but the key element to diagnosis is
if the ejaculation occurs before, on, or just after penetration and that too
before the man wants it then the individual may be diagnosed with early
ejaculation disorder. This is because, in sexually normal men, the ejaculatory
impulse is under voluntary control, at least to some extent. They can
forestall ejaculation from penetration to almost 10 minutes. Men with early
ejaculation are unable to do so effectively. There can be a variety of factors
working behind it such as higher anxiety levels, high penile sensitivity
or high levels of arousal to sexual stimuli. Yet, the explanation remains
insufficient to understand the reasons behind early ejaculation.
Treatment: Behavioural therapy has been used a lot to deal with the issue
of early ejaculation, especially the technique of ‘pause-and-squeeze’ as
developed by Masters and Johnson (1970). But, some recent studies have
reported lower success rate of the technique (Duterte et al. 2007). It has been
found that the antidepressants such as Paroxetine, Sertraline, Fluoxetine and
Dapoxetine are helpful in prolonging ejaculation as it blocks the serotonin
reuptake (Jannini & Porst, 2011).
Box 5.4: DSM-5 Criteria for Premature (early) Ejaculation Disorder
(APA, 2013)
A. A persistent or recurrent pattern of ejaculation occurring during
partnered sexual activity within approximately 1 minute following vaginal
penetration and before the individual wishes it.
Note: Although the diagnosis of premature (early) ejaculation may be
applied to individuals engaged in nonvaginal sexual activities, specific
duration criteria have not been established for these activities.
B. The symptom in Criterion A must have been present for at least 6
months and must be experienced on almost all or all (approximately 75–
100 percent) occasions of sexual activity (in identified situational contexts
or, if generalised, in all contexts).
C. The symptom in Criterion A causes clinically significant distress in the
individual.
5.4.4 Delayed Ejaculation Disorder
It refers to the inability to ejaculate during intercourse in men. Men with
total inability to ejaculate are rare and about 85 percent of men who have
delayed ejaculation disorder can achieve orgasm by getting stimulation in
other ways, mainly during solitary masturbation (Wincze et al., 2008). In
some other cases, men can ejaculate in front of the partner but only through
manual or oral stimulation. Delayed ejaculation can also be due to physical
issues such as multiple sclerosis or use of some antidepressants.
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Mental Disorders- II Treatment: Couple therapy in which man tries to achieve orgasms through
intercourse with a partner has found to be effective. It is important to
reduce the performance anxiety about achieving the orgasm versus sexual
gratification and intimacy (Meston & Rellini, 2008). This is also done using
behavioural therapy and cognitive behavioural therapy approaches.
Box 5.5: DSM-5 Criteria for Delayed Ejaculation Disorder (APA,
2013)
A. Either of the following symptoms must be experienced on almost all or
all occasions (approximately 75–100 percent) of partnered sexual activity
(in identified situational contexts or, if generalised, in all contexts), and
without the individual desiring delay:
1) Marked delay in ejaculation.
2) Marked infrequency or absence of ejaculation
individual.
5.4.5 Female Sexual Interest/Arousal Disorder
As per the research, women who have low sexual desire also have lower
levels of arousal during sexual activity and thus, for women, DSM- 5 has
combined the category of interest and arousal in the disorder, Female Sexual
Interest/Arousal Disorder. Psychological factors have an important role to
play in reduced sex drive (Meston & Bradford, 2007). There is one slight issue
with the diagnosis of this disorder. People usually come to get themselves
treated on the behest of their partners and also due to readily available public
knowledge on their own owing to their understanding of frequency of sexual
contact. It is important to know that frequency of sexual contact vary widely
among normal individuals, therefore, it becomes difficult to decide what is
“not enough” and would require clinical intervention. DSM-5 leaves this
judgment to the clinician on the basis of patient’s age, and life context. If
a person has depression or had it in the past, that could also contribute to
sexual desire disorder (Meston & Bradford, 2007). Testosterone may also
have a role to play in diminishing sexual desire but testosterone replacement
therapy is beneficial (both in men and women) only in the cases of people
with very low testosterone (Meston & Rellini, 2008).Daily hassles, worries,
poor relationship and lesser satisfaction, conflicts and disagreements, weak
or reducing emotional bonding may also contribute to sexual desire disorder
(Meston & Rellini, 2008).
Until recently, female sexual desire and the disorders related to it was not
given a lot of importance. This could have been due to sweeping mindset
and a myth that women do not care much about sex. But recently, some
findings have suggested that a linear progression from desire to arousal and
finally orgasm, as originally posited, might not be there always in the case
of women (Meston & Bradford, 2007). For many women sexual desire is
experienced only after sexual stimuli has led to subjective sexual arousal
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(Basson, 2003; Meston & Bradford, 2007). For some sexual activity may act Sexual Disorders and Gender
as a motivator to enhance emotional intimacy or self-image as an attractive Dysphoria
woman (Basson, 2003, 2005).
Major manifestation of sexual arousal disorder is failure to achieve the
swelling and lubrication of the vulva and vaginal tissues making sexual
intercourse difficult and uncomfortable. The cause is not being researched
upon very well but it could range from sexual traumatisation at an early stage
to the twisted and tabooed views of the society about “sex”. It could also be
due to disinterest in the current some sort of medical illness (Diabetes, some
injury etc.), and reduced levels of estrogen especially during menopause.
Treatment: No effective aphrodisiacs exist as such to help in enhancing
sexual desire. As mentioned earlier, injecting testosterone works with men
and women who have very low testosterone levels. Some studies (such as
Segraves et al. 2004) have highlighted that continuous use of Bupropion
(antidepressant), may improve sexual arousal and orgasm frequency in
women with hypoactive sexual desire disorder. Very much like other sexual
dysfunctions, patients are taught some sensate focus exercises involving
couples to learn to focus on pleasurable sensations by touching without
making intercourse or achieving orgasm as a major goal.
Box 5.6: DSM-5 Criteria for Female Sexual Interest/Arousal Disorder
(APA, 2013)
A. Lack of, or significantly reduced, sexual interest/arousal, as manifested
by at least three of the following:
1) Absent/reduced interest in sexual activity.
2) Absent/reduced sexual/erotic thoughts or fantasies.
3) No/reduced initiation of sexual activity, and typically unreceptive to
a partner’s attempts to initiate.
4) Absent/reduced sexual excitement/pleasure during sexual activity in
almost all or all (approximately 75–100 percent) sexual encounters
(in identified situational contexts or, if generalised, in all contexts).
5. Absent/reduced sexual interest/arousal in response to any internal or
external sexual/erotic cues (e.g., written, verbal, visual).
6. Absent/reduced genital or nongenital sensations during sexual
activity in almost all or all (approximately 75%–100%) sexual
encounters (in identified situational contexts or, if generalized, in
all contexts).
B. The symptoms in Criterion A have persisted for a minimum duration
of approximately 6 months.
C. The symptoms in Criterion A cause clinically significant distress in
the individual.
disorder or as a consequence of severe relationship distress (e.g.,
partner violence) or other significant stressors and is not attributable
to the effects of a substance/medication or another medical condition.
5.4.6 Genito-Pelvic Pain/Penetration Disorder
DSM-IV-TR had mentioned two sexual pain disorders: vaginismus and
dyspareunia which have been combined in DSM-5 because of lack of
scientific report to support distinct categories (Binik, 2010). Vaginismus
was understood to be an involuntary spasm of the muscles near the vaginal
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Mental Disorders- II entrance, thus preventing penetration and sexual intercourse. But these
vaginal spasms could not be reliably diagnosed and women who were
diagnosed with vaginismus basically complained of pain during penetration
and anxiety before and during sexual intercourse (Reissing et al. 2003).
Confusion over difference between the two is over the fact that the hallmark
symptom of vaginismus does not occur clearly whereas the chief symptom
of dyspareunia (genital pain associated with sexual intercourse encounters)
is common in women with vaginismus as well. Thus, in DSM-5 both have
been combined together. Studies have revealed that genito-pelvic pain
disorder has more of a biological basis than psychological. It could occur
due to infections or inflammation of vagina, vaginal atrophy that may occur
with age, scars and bruises from vaginal tearing or lack of sexual arousal.
Some researchers have argued against categorising sexual pain disorders as
sexual disorders (Binik, 2005; Binik et al., 2007) as the pain caused here
is qualitatively similar to the pain in other areas of the body and even the
cause of pain is similar to other pain disorders. Thus, they have argued to
categories these as pain disorders.
Treatment: Cognitive- behavioural interventions including education
about sexuality, cognitive restructuring, progressive muscular relaxation
and vaginal dilation exercises have been found to be effective in sexual
pain disorders (Bergeron, Biniketal., 2001). Some medical treatments such
as surgical removal of the vulvar vestibule has been found to be successful.
Box 5.7 DSM- 5 Criteria for Genito-pelvic Pain/Penetration Disorder
(APA, 2013)
A. Genito-pelvic pain/penetration disorder is defined as persistent or
recurrent difficulties with one or more of the following:
1) Vaginal penetration during intercourse.
2) Vulvovaginal or pelvic pain during vaginal intercourse or attempts
at penetration.
3) Fear or anxiety about vulvovaginal or pelvic pain in anticipation of,
during, or as a result of vaginal penetration.
4) Tightening or tensing of the pelvic floor muscles during attempted
vaginal penetration.
In order to meet the diagnostic criteria, at least one of the above mentioned
symptoms must have persisted for at least six months and must cause
significant distress. The disorder can be specified by severity and as either
lifetime or acquired.
5.4.7 Female Orgasmic Disorder
Female orgasmic disorder can be diagnosed in women who have no issues
pertaining to sexual arousal or otherwise enjoying sexual activity but show
recurrent delay or absence of orgasm after the excitement phase (as per DSM-
5). They would also be distressed by this. Achieving orgasm through clitoral
stimulation during sexual intercourse is such a common occurrence and thus
is not regarded as a dysfunction (Meston & Bradford, 2007). However,there
is a small percentage of women who can achieve orgasm only through
direct mechanical stimulation of clitoris, oral stimulation or through electric
vibrators. And, there are some who are unable to achieve orgasm under any
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sort of stimulation, called as lifelong orgasmic dysfunction. The diagnosis Sexual Disorders and Gender
of orgasmic dysfunction in women has always been complicated due to Dysphoria
the subjective quality of orgasm, as it varies from one woman to another
or within the same woman from time to time (Graham, 2010). There can
be various contributory factors towards female orgasmic disorder such as
feeling fearful about the sexual relationship, feeling of inadequacy, anxiety
and tension. Some women also tend to experience sexual guilt. Some other
try to pretend having an orgasm or fake orgasms, this may leave them
irritated and frustrated with themselves and eventually their partners as
well. Yet, researchers have not been able to identify the cause with certainty.
Possible biological factors responsible here could be intake of SSRIs. Some
recent evidences have suggested that the genital anatomy of women and the
differences in it (from one to another) may allow some to achieve orgasm
more easily than others (Wallen & Lloyd, 2011).
Treatment: There has always been questions if treatment should be sought
for orgasmic disorder (especially in women) and clinicians have come to
agree that the decision should be best left to women themselves about it.
But, in cases with lifelong orgasmic disorder it is best to seek treatment.
Cognitive behavioural treatment involves education about anatomy,
sexuality and masturbation exercises. Gradually the partner is involved in
helping to attain orgasm (Meston &Rellini, 2008). It is important to note
here that situational anorgasmia may have psychological and relationship
related issues involved and are more difficult to treat (Althof & Schreiner-
Engel, 2000).
Box 5.8: DSM-5 Criteria for Female Orgasmic Disorder (APA, 2013)
A. Presence of either of the following symptoms and experienced on almost
all or all (approximately 75–100 percent) occasions of sexual activity (in
identified situational contexts or, if generalised, in all contexts):
1) Marked delay in, marked infrequency of, or absence of orgasm.
2) Markedly reduced intensity of orgasmic sensations.
individual.
disorder or as a consequence of severe relationship distress (for example, ,
partner violence) or other significant stressors and is not attributable to the
effects of a substance/medication or another medical condition.
Check Your Progress II

1) What is sexual dysfunction?
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Mental Disorders- II
5.5 GENDER DYSPHORIA
The essence of masculinity and femininity is a deep-seated personal sense
and has been termed as gender identity which is different from gender roles.
Gender roles are about the masculinity and femininity of overt behaviour.
Although gender identity has a strong correlation with the biological sex,
but the correlation is not perfect. Some people feel as if they are trapped in a
body of wrong sex, that is, their physical gender is not consistent with their
sense of identity.
As per DSM-5, Gender Identity Disorder is termed as Gender Dysphoria.
It is the discomfort one has with one’s sex-based physical characteristics or
with one’s societally assigned gender. The change has been made to make
the diagnosis more descriptive and theoretically as neutral as possible. So,
people who were diagnosed with gender identity disorder (GID) earlier will
certainly experience gender dysphoria. It has been taken into consideration
that the degree of dysphoria may vary or fluctuate over a period of time
within the same individual (Cohen- Kettenis & Pfafflin, 2010). Gender
dysphoria can be diagnosed either during adolescence or adulthood or even
at the childhood stage.
DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults (APA,
2013) is as follows:
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.
5.5.1 Gender Dysphoria in Childhood
Boys who have gender dysphoria usually show a marked preoccupation
with the activities which are typically and traditionally defined as feminine
144
(Zucker & Bradley, 1995). They prefer to dress like girls and enjoy activities Sexual Disorders and Gender
and games like playing with dolls or playing house. While playing house, Dysphoria
they most often become a mother. They usually avoid rough play behaviour
and express their desire to be a girl. They may like watching shows with
their favourite woman character. They are often laughed upon called as
“sissies” by their friends.
Girls with gender dysphoria usually recoil or become hesitant at their
parents’ attempt to dress them up in traditional feminine clothes. They prefer
short hair and fantasise typically powerful heroes like ironman, superman
etc. They show lesser interest in playing with dolls and rather are interested
in other sports. They look like what we call as ‘tomboys’ but differ from
them due to their desire to be a boy or grow up as a man. They are often
misidentified by strangers as boys. Usually girls with gender dysphoria are
treated better in comparison to boys with gender dysphoria (Cohen-Kettenis
et al. 2003).
It is interesting to note that most common adult outcome of boys with gender
dysphoria is homosexuality rather than transsexualism (opting for surgeries
for sex change) (Zucker, 2005). Researchers over the years have argued
that such children should not be considered “disordered” as they might be
unhappy due to the societal pressure and bias of negative attitude towards
cross-gender behaviour. But some others have concluded it to be due to
the discrepancy between their biological sex and psychological gender and
are called as with mental disorder (Zucker, 2005). Also, they are laughed
upon and mistreated by their peers, have tensed relationships with their
parents leading to their distress eventually. It is again important to note here
that some cultures (like Samoa) do not show stigma towards gender non-
conforming children (Vasey & Bartlett, 2007).
DSM-5 Criteria for Gender Dysphoriain Children (APA, 2013): DSM
Criteria for Gender Dysphoria in Children (APA, 2013) is as follows:
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
145
Mental Disorders- II toys, games, and activities and a strong avoidance of rough-and-
tumble 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.
Treatment: For children and adolescents with gender dysphoria the attempt
is to mainly deal with child’s unhappiness with the biological sex and to
ease the relationship with the parents (Zucker et al. 2008). They may also
have mood and anxiety related issues that may need therapeutic attention.
To treat gender dysphoria, psychodynamic perspective has been found to be
helpful herein the inner conflicts are examined, understood and resolved.
Two important facts to note about gender dysphoria are: first, for most
children with gender dysphoria, the problem remits during childhood only
(Wallien & Cohen-Kettenis, 2008). Second, children who remain with
dysphoria till their adolescence may remain so even in their adulthood and
may opt for sex reassignment surgeries.
5.5.2 Transsexualism
Adults with gender dysphoria may have a desire to change their sex
permanently and transit to the gender with which they identify, it is called as
transsexualism. This is usually done by seeking medical assistance (Cohen-
Kettenis & Pfafflin, 2010). It is perhaps a rare disorder as some of the past
European researches have suggested that about 1 in 30,000 males and 1
in 100,000 females seek this sex reassignment surgery. But some recent
studies have suggested that approximately 1 in 12,000 men in Western
countries opt for it (Lawrence, 2007).
It is important to note that many transsexuals had gender dysphoria as
children but most children who have gender dysphoria do not opt for sex
reassignment surgeries. Most of the female-to-male transsexuals recall being
‘tomboyish’ as children and most of them are sexually attracted to women.
But, in the case of male-to-female transsexuals there can be two kinds-
homosexual and autogynephilic transsexuals (Bailey, 2003). Homosexual
transsexuals are very much like gay men with same sex orientation. So,
they are attracted to males, which is their biological sex before the surgery.
But, because they identify themselves as women, they often define their
sexual orientation as heterosexual. For autogynephillic transsexuals, they
are attracted to thoughts, images or fantasies of themselves as women
(Blanchard, 1991, 1993).
Attempts have been made to understand transsexualism. One of the
hypotheses in this regard says that there could be some prenatal hormonal
influences due to which children with gender identity disorder may later
become transsexuals (Meyer-Bahlburg, 2010). There is also a possibility
that some families are more in support of their boys’ ‘defeminization’ as
compared to others. It is also important to highlight that they are different
146
from people with transvestic fetishism as their purpose of cross dressing Sexual Disorders and Gender
is not sexual arousal or gratification. Here, the goal is to live life in a Dysphoria
manner that is consistent with that of the gender they prefer to be. They
must also be distinguished from intersex individuals as they are not born
with ambiguous genitalia or associated with any hormonal or physical
abnormalities.
It has been agreed upon that usually psychotherapy is not very effective
with adolescents or adults with gender dysphoria (Cohen-Kettenis,
Dillen & Gooren, 2000; Zucker & Bradley, 1995). However, surgical sex
reassignment has been found to be effective. Biological men are given
estrogen for breast development, skin softening etc. and biological women
are given testosterone to increase facial and bodily hair, deepen the
voice and cease menstruation. Living with hormonal therapy serves as a
trial period for them before undergoing surgery. Only a small section of
female-to-male transsexuals seek an artificial penis as the surgery is quite
expensive and also not very well developed. Another important point to
consider here is that the artificial penis is not capable of erection and thus
they must always rely on artificial ways to have intercourse. Thus, many
also function sexually without penis.
Check Your Progress III
1) What is gender dysphoria?
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Box 5.9 Paraphilic Disorder

Paraphilias are recurrent, intense sexually arousing fantasies, urges
and behaviour that involve (a) non-human objects (shoes, hair, etc), (b)
suffering or humiliation of oneself or partner (c) children or other non-
consenting people. It is to be diagnosed if the condition lasts at least for 6
months. Here, there is deviation (para) in something that the individual is
attracted to (philia).
Diagnosing paraphilias have always remained challenging due to a few
reasons; with some paraphilias, the individual (having the paraphilia) does
not experience distress in himself/herself. For instance, a pedophile who
has assaulted and molested child does not feel guilty about it. However,
it has been considered as a mental disorder due to its impact on others
(especially the child). Another important aspect here is the fact that
there are some categories of paraphilias which are also compatible with
psychological health and happiness and may neither have signs of distress
and may also involve two consenting adults.For instance, someone with a
foot fetish may find a partner comfortable with this sexual interest and may
readily indulge in it, while, some others may experience shame and guilt
in expressing such a desire. Thus, paraphilias are unusual sexual interests,
not causing harm to the individual or others. It is only if they cause harm,
they are considered as paraphilic disorders (Blanchard, 2010).
147
With time, some of these behaviours are also becoming more common,
raging a debate if it is appropriate to diagnose some of these behaviours
as paraphilic disorders. Fetishistic disorder, sexual sadism and transvestic
disorders have not been included in the classification system of the
Swedish National Board of Health and Welfare (Langstrom, 2010), stating
reasons that people practice variants of sexual behaviour safely and with
consenting adult partners thus, not to be diagnosed. Paraphilias have a
compulsive quality to themselves and as per research some individuals
require orgasmic release as often as 5 to 10 times a day (Garcia & Thibaut,
2010).
Fetishistic Disorder: The fetishistic disorder is marked by recurrent,
intense sexually arousing fantasies, urges and behaviours that involve
the use of some inanimate object or part of the body to obtain sexual
gratification. Clothing (especially undergarments), leather (garter belts
etc.) and articles related to feet (women’s shoes, stockings) are considered
to be common fetishes. Apart from this, some people focus on certain non-
sexual parts of the body such as, nails, feet, hands, hair etc. for arousal.
According to DSM-5, it is characterised as a condition with persistent use
of or dependence on non-living objects or specific focus on a body part
(non-genital) for sexual arousal. In the earlier versions of DSM, arousal
revolving around non-genital body parts was called as partialism. DSM-5
included partialism into fetishistic disorder.
Majority of the reported cases of fetishism are of males, female fetishists
are extremely rare (Mason, 1997). Some continue their fetish by themselves
in secrecy by kissing, smelling, sucking, fondling or just gazing at the
object of interest while masturbating. Others ask their partners to put on
the fetish as a stimulant for intercourse. The attraction for a fetishist may
seem involuntary and irresistible- compulsive in nature. The disorder may
begin in adolescence, although it may acquire its special significance even
earlier than this, that is, during childhood. In order to obtain the required
object of arousal, some men may even commit theft, burglary or assault.
It has been seen that that articles that are most commonly stolen by them
are women’s undergarments.
One common hypothesis regarding causality of fetishism focuses on
classical conditioning and social learning theories (Hoffman, 2012). For
example, female undergarment is closely linked to the act of sex and
the female body thus becoming an object of arousal. The person with
fetishistic disorder feel compulsively attracted towards the object of
interest, the attraction is experienced as involuntary and irresistible. The
degree of erotic focus is what distinguishes fetishistic disorder from an
ordinary attraction.
DSM-5 Criteria for Fetishistic Disorder (APA, 2013)
A. Over a period of at least 6 months, recurrent and intense sexual arousal
from either the use of nonliving objects or a highly specific focus on
nongenital body part(s), as manifested by fantasies, urges, or behaviours.
B. The fantasies, sexual urges, or behaviours cause clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.
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Sexual Disorders and Gender
C. The fetish objects are not limited to articles of clothing used in cross-
Dysphoria
dressing (as in transvestic disorder) or devices specifically designed for
the purpose of tactile genital stimulation (for example, , vibrator).
DSM-5 Criteria for Transvestic Disorder (APA, 2013)
from cross-dressing, as manifested by fantasies, urges, or behaviours.
functioning.
Voyeuristic Disorder: A young, married man lived in an attic apartment
with his wife. The wife went out to work in order to enable her husband to
attend his school and run the household. She would usually come home
late at night tired and irritable and often in no mood for indulging in
sexual activity. They also mentioned that “the damned springs in the bed
would squeak” perhaps further dampening her spirits. In order “to obtain
some sexual gratification”, he would try to look through his binoculars at
the room next door and would see the young couple there engaged in erotic
activities occasionally. As this would stimulate him highly, he continued
with this activity. During his second endeavour, he was reported to the
police. This offender was found to be immature for his age, moralistic in
his attitude towards masturbation and sex, and prone to engage in rich but
immature sexual fantasies.
According to DSM-5, Voyeuristic disorder involves a recurrent and intense
desire to obtain sexual arousal and gratification by watching others in a
state of undress (especially women) or couples engaging in sexual activity.
Such individuals usually masturbate during their peeping activity and
achieve orgasm either while watching the activity or wile remembering
the peeping activity. They are commonly called as ‘Peeping Tom’ (mostly
men). For some men with this disorder, voyeurism is the only sexual
activity they indulge in; for others, it might be a preferred one but not
absolutely necessary for sexual arousal (Kaplan & Kreuger, 1997).
A true voyeur is not excited by watching a woman who is undressing for
his benefit. It is the element of risk that is important for the voyeur, and
the anticipation of the reaction of woman once she would get to know
about him watching her. People with this disorder are mostly charged with
loitering than with peeping (Kaplan & Kreuger, 1997).
Voyeurism commonly occurs with other paraphilias such as exhibitionism
(Langstrom & Seto, 2006).
DSM-5 Criteria for Voyeuristic Disorder (APA, 2013)
from observing an unsuspecting person who is naked, in the process of
disrobing, or engaging in sexual activity, as manifested by fantasies, urges,
or behaviours.
B. The individual has acted on these sexual urges with a nonconsenting
person, or the sexual urges or fantasies cause clinically significant
functioning.
149
C. The individual experiencing the arousal and/or acting on the urges is at
least 18 years of age.
Exhibitionistic Disorder: It is a recurrent and intense urge, fantasy or
behaviour to obtain sexual gratification by exposing one’s genitals to others
(usually unwilling strangers) without their consent and in inappropriate
circumstances. Very much like voyeuristic disorder, there is rarely an
attempt to have an actual contact with the stranger. In some cases, the
exposure of genitals is also accompanied by suggestive, vulgar gestures or
even masturbation. The exposure may take place in any secluded location
or sometimes even in certain public spaces.
It has been understood that the element of shock is highly arousing to these
individuals. In many instances, the exposure is repeated under constant
sort of conditions. For instance, the offender may exhibit himself at the
same place or at the same time of the day every time. For male offenders,
in most cases the victim is usually a young or middle aged woman who is
unknown (stranger) to the offender. Children and adolescents could also
be a target of the offenders.
Exhibitionism is commonly seen to co-occur with voyeurism,
sadomasochistic interest and cross-dressing (Langstrom, 2010). It is
mainly the intrusive aspect of the whole act, along with the violation
of norms related to modesty, respect and privacy of an individual about
“private parts”, due to which exhibitionism has been considered as a
criminal offense.
The urge of the exhibitionist to expose is overpowering and uncontrollable
and is perhaps triggered by anxiety, restlessness and sexual arousal. It is
perhaps due to the compulsive nature of the urge that the act is repeated, in
many cases at the same place and even at the same time of the day. After
the act, they may regret and repent it, but in the tension of the moment they
may not even care for the legal obstructions.
DSM-5 Criteria for Exhibitionistic Disorder (APA, 2013)
A. Over a period of at least 6 months, recurrent and intense sexual
arousal from the exposure of one’s genitals to an unsuspecting person, as
manifested by fantasies, urges, or behaviours.
functioning.
Sexual Sadism and Masochism Disorders: Both sadism and masochism
are about wither inflicting pain (sadism) on others or suffering pain
themselves (masochism) (Hucker, 2008). The term sadism is derived from
Marquis de Sade’s name (1740-1814) who would meet out cruelty for
sexual purposes. As per DSM-5, a person is to be diagnosed with sadism if
he expresses intense sexually arousing urges and behaviours that involve
meting out physical and/or psychological pain on another individual.
Another closely related pattern to this is “bondage and discipline” (B &
D), that may involve tying up a person, hitting, spanking etc. for sexual
pleasures. A number of sexually sadistic acts also occur in a consensual
150
sexual relationship without any evident harm to the partners involved.
Dysphoria
Thus, it becomes all the more important to distinguish transient or
occasional sadomasochistic behaviours from sadism or masochism as a
paraphilia.
A very small section of males with sexual sadism also enjoy inflicting
pain and humiliation acts that are non-consensual and could also be fatal
(Krueger, 2010). A sadist may slash a woman’s wrist, spank her, tie her up
using a harness, and stick her up with a needle to experience orgasm. The
act may vary in intensity from one sadist to another, from fantasy to severe
disfigurement, damage and even murder in some cases. The diagnosis also
includes an important aspect where the victim is to be non-consenting
or the one with experience of marked distress and difficulties. In certain
cases, sadists are found to mentally replay their torture and harm inflicted
on others later while masturbating to attain orgasm. One promising and
very important modification that is being worked on is a dimensional
approach that could differentiate sexual sadists who are dangerous (like
some of the serial killers involved in sadomasochistic tendencies) from
those who are not (Krueger, 2010).
The term masochism has been derived from the Austrian novelist, Leopold
V. Sacher-Masoch (1836-1895). His fictional characters would often
indulge in sexual pleasure of pain. According to DSM-5, to be diagnosed
with sexual masochism disorder, the person must have experienced
recurrent and intense sexually arousing fantasies or behaviours that would
involve acts of being beaten, bound or humiliated. However, some forms
of masochism can be further worrisome- such as autoerotic asphyxia,
that involves self-strangulation. The loss of oxygen to the brain could be
resulting on sexual pleasure and orgasm. In some cases, something or the
other may go wrong which would result in the individual harming himself
by accidentally hanging himself. It may look absurd and even ironic
that inflicting or receiving pain could be sexually arousing, but it is not
uncommon. Some of these behaviours are also usually mild and harmless
(Krueger, 2010).
DSM-5 Criteria for Sexual Sadism Disorder (APA, 2013)
A. Over a period of at least 6 months, recurrent and intense sexual
arousal from the physical or psychological suffering of another person, as
manifested by fantasies, urges, or behaviours.
functioning.
DSM-5 Criteria for Sexual Masochism Disorder (APA, 2013)
from the act of being humiliated, beaten, bound, or otherwise made to
suffer, as manifested by fantasies, urges, or behaviours.
functioning.
151
Pedophilic Disorder: Pedophilia is also called as pedohebephilllic
disorder wherein, pedes is Greek for “child”, hebe is “pubescence” and
phillia means “attraction”. Thus, it is diagnosed when adults are said to
derive sexual pleasure (recurrent, intense and distressing desire and urge)
through sexual contact with prepubertal children. DSM-5 requires the
offender to be at least 18 years old and at least 5 years older than the
child. Most people with the said disorder report to use child pornography
to sexually gratify themselves (Riegel 2004) and thus it has been added in
the DSM-5 criteria. Action is not considered necessary for the diagnosis.
A person with this disorder is sometimes content with just stroking the
child’s hair, but may also be found to be fondling with the child’s genitalia
or encouraging the child to manipulate his/her genitalia. Penetration
although can cause injury but is not the goal, it could be a by- product of
the activity. If not found by adults or protested by the child, such acts may
continue for months or even years. Thus, it is considered to be the most
tragic sexual deviance (Blanchard, 2010).
Almost all the individuals with pedophilia are males, and about 2/3rd of
their victims are young girls, between the ages of 8 and 11 (Cohen &
Galynker, 2002). Pedophilia is usually first recognized in the adolescence
and then may persist for a lifetime. These child molesters are usually found
to engage in various cognitive distortions which are self- justifying in
nature, such as, the child will benefit from the sexual contact and that the
child often initiates such contact (Marziano et al. 2006). Some pedophiles
have been found to idealise innocence, unconditional love and simplicity-
the core aspects of childhood (Cohen & Galynker, 2002). It has also been
discovered the majority of the offenders have themselves been abused as
a child (Lee et al. 2002).
The World Health Organization has defined main types of child abuse as
physical abuse, sexual abuse, emotional abuse, and neglect. Child sexual
abuse (CSA) has increased over the years not only in India but the world
over. The spaces like home, schools, hotel, and other public places, have
witnessed CSA. The experience has a traumatic effect resulting in changes
in the brain, physical and psychological problems like depression, post
traumatic disorder, suicide and such other disorders. The Government
of India passed The Protection of Children from Sexual Offences Act
(POCSO)in 2012 to effectively address the menace of CSA. POCSO
Act was modified in 2019 to include death penalty fo raggravated sexual
assault, strict punishment to those engaging in crimes against children,
levying fines and imprisonment to curb child pornography. To facilitate
direct reporting of CSA and timely disposal of cases, the Ministry of
Women & Child Development launched POCSO e-box.
DSM-5 Criteria for Pedophilic Disorder (APA, 2013)
A. Over a period of at least 6 months, recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours involving sexual activity with a
prepubescent child or children (generally age 13 years or younger).
B. The individual has acted on these sexual urges, or the sexual urges or
fantasies cause marked distress or interpersonal difficulty.
152
C. The individual is at least age 16 years and at least 5 years older than the
Dysphoria
child or children in Criterion A.
Note: Do not include an individual in late adolescence involved in an
ongoing sexual relationship with a 12- or 13-year-old.
Incest: In 2007, the case of an Austrian incest perpetrator Josef Fritzl
shook the entire world. He had kidnapped his daughter Elisabeth when the
girl was 18 and had imprisoned her in a soundproof compartment that he
had built in the basement of his house. The girl was forced to write a note
stating that she had joined a cult and was thus leaving the family. During
her long imprisonment, she was repeatedly forced by her father to indulge
in sexual activity. She bore seven of his children, one of whom died in
infancy. Three children were reared by the family upstairs and other three
lived with her in the basement. Owing to one of the child’s illness, she
went to the hospital and there the staff found Fritzls’ story to be suspicious
finally leading to investigation and ending Elisabeth’s ordeal (Dahlkamp
et al. 2008).
Incest refers to sexual intimacy and relations between close relatives,
between whom marriage is forbidden as per the societal norms. These
are culturally prohibited sexual relations between brother and sister or a
parent and child. One of the most pathological ones being the relationship
between father and daughter. Incest is considered as a taboo in almost
all the societies with Egyptian pharaohs being an exception, who would
marry their sisters to save royal blood from “contamination”. According to
present scientific knowledge, incest may have a legitimate reason behind
it. The offspring from a father-daughter or brother- sister pair will have a
greater possibility of inheriting a recessive gene from each parent, which
might be a carrier of some disease or disorder. Thus, avoiding mating
between close relatives to evade some mental and physical illnesses. As
per the evidence, families with cases of incest are usually extremely male
dominated and patriarchal and the parents are also usually more neglectful
and emotionally distant (Madonna, Van Scoyk & Jones, 1991).
Treatment: Most of the behaviours involved in paraphilias is considered
to be illegal. Thus, someone diagnosed with it is usually imprisoned and
then treatment is given to them. How to enhance motivation to change the
behaviour?
Usually people with paraphilias deny having a problem and state that
they can control their behaviour on their own without any professional
assistance. A lot of times the blame is shifted on the victims. Following
tips can be followed to enhance their motivation to change (Miller &
Rollnick, 1991)
1) It is important to feel empathetic towards the reluctance of the
offender to admit his/her state and seek treatment.
2) Point out how treatment could be of possible help to him/her and its
positive consequences.
3) Highlight the negative consequences of refusing the treatment- both
legal and personal.
153
4) Make him/her understand that how psychophysiological assessments
will make the sexual tendencies and proclivities very clear.
Behaviour therapy is mainly directed at altering the associations from
arousing to neutral. Covert sensitization is used for it, where short-
term pleasure usually overweighs long-term harm because of the strong
immediate reinforcement and gratification it is providing. So, the patients
are asked to associate sexually arousing images (in imagination) with
reasons as to why they are harmful.
Cognitive procedures are also used to counter distorted views and modify
them. Therapists also use social skill training and sexual impulse training
to modify these thinking patterns (Maletzky, 2002). Empathy based
training modules are also designed to help the sexual offenders.
A popular drug used to treat people with paraphilias is an androgen named
cyproterone acetate (Seto, 2009). This is like “chemical castration” wherein
the drug reduces or eliminates the sexual desire by decreasing testosterone
levels in the body. Another one that is used is, medroxyprogesterone
(Fagan et al., 2002). These drugs are effective only when taken regularly.
5.6 LET US SUM UP

Now that we have come to the end of this unit, let us list all the major
points that we have learnt.
Sexuality is considered to be one of the most private aspects of life which
may contribute to love, happiness and pleasure. Sex is considered as a
taboo in various societies and cultures and in many societies, it is talked
openly.
The human sexual cycles consist of desire phase, arousal phase, plateau
phase, orgasm phase and resolution phase.
The common sexual dysfunctions in men are delayed ejaculation, erectile
dysfunction, and early ejaculation. In females, the sexual dysfunctions
are female orgasmic disorder, female sexual interest/arousal disorder, and
genito- pelvic pain/penetration disorder.
Psychological and medical treatment options are available for sexual
dysfuctions.
Paraphilias are recurrent, intense sexually arousing fantasies, urges and
behaviour that involve non-human objects (shoes, hair, etc.); suffering or
humiliation of oneself or partner; children or other non-consenting people.
It is to be diagnosed if the condition lasts at least for 6 months.
The paraphilic disorders are fetishistic disorder, transvestic disorder,
voyeuristic Disorder, exhibitionistic disorder, sexual sadism disorder,
sexual masochism disorder, and pedophilic disorder.
Neurobiological and psychological factors play an important role in the
etiology of paraphilias.
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5.8 KEY WORDS

Paraphilias: Recurrent, intense sexually arousing fantasies, urges and
behaviour that involve (a) non-human objects (shoes, hair, etc), (b) suffering
or humiliation of oneself or partner (c) children or other non-consenting
people.
Sexual dysfunction: Impairment in the desire or ability to achieve sexual
pleasure and gratification. It can mainly be divided in 3 categories: those
involving sexual desire and arousal; orgasmic disorders and sexual pain
disorders.
Transexualism: When adults with gender dysphoria may have a desire to
change their sex permanently and transit to the gender with which they
identify.
5.9 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress I
1) List the phases in human sexual response cycle.
Phases in human sexual response cycle:
●● Desire phase
●● Arousal phase
●● Plateau phase
●● Orgasm phase
●● Resolution phase
Check Your Progress II
1) What is sexual dysfunction?
Sexual dysfunction refers to impairment in the desire or ability to achieve
sexual pleasure and gratification.
Check Your Progress III
1) What is gender dysphoria?
It is the discomfort one has with one’s sex-based physical characteristics or
with one’s societally assigned gender.
160
5.10 UNIT END QUESTIONS Dysphoria
1) Discuss the causal factors in the etiology of paraphilias.
2) Elucidate the role of socio-cultural factors in development of gender
differences in sexuality.
3) Describe the paraphilic disorders as listed in DSM-5.
4) Explain the development of gender identity disorder in children.
5) What are the main criteria for sexual dysfunctions in men and women?
Discuss the treatment approaches.
5.11 WEB RESOURCES

●● Understanding Paraphillic Disorders and Treatment of sexual
offenders https:/www.youtube.com/match?v=-z-29ihOj8&=17s
●● Sexual offending: Measuring and understanding paedophilic
sexual interest by Dr. Carolite O. Ciardha
http://www.youtube.com/watch? v=GVIyah XoOg
161
Diagnoses and treatment of psychological disorders
The most important step in determining the treatment process of any
psychological disorder is diagnosis. It is important to note that mere
presence of symptoms is not an indication of presence of a disorder. For
instance, we may often feel anxious before an interview or an examination
or we may also feel upset about a certain loss but that does not mean
that we are suffering from an Anxiety Disorder or Depression. DEGREE
and DURATION of symptoms id often relevant in diagnosis. Also it is
important that the diagnosis needs is carried out by a professional and
certified person so that the individual receives adequate treatment. If a
person has fever due to malaria but is wrongly diagnosed as having flu,
can have detrimental effects on health of the individual as the symptoms
will not alleviate and the illness can deteriorate.
Diagnosis of psychological disorder includes taking a detailed case history
of the individual, carrying out Mental Status Examination (MSE), Using
interview with the individual as well as his/ her family and significant
others (could be friends and colleagues), Using psychological tests for
diagnosis and also behavioural assessment.
Once the diagnosis is carried out then psychotherapy can be used. Though
for certain psychological disorders medication is also required but the
same are prescribed by a Psychiatrist. A clinical psychologist cannot
prescribe medication. In simple terms psychotherapy can be explained
as an interaction between two individuals, one of whom is displaying
distress and the other is skilled and qualified, having necessary expertise
in psychotherapy. And these individuals decide to work together with an
aim to help the individual in distress deal with his/ her distress.
Psychotherapy is different from counselling (that you must frequently
heard about. Psychotherapy is much more in-depth and a long term process
when compared with counselling. In psychotherapy various therapies are
used and in counselling certain techniques like listening, questioning and
so on are employed. Some of the psychotherapies are listed below:
- Psychodynamic Approach
- Existential Therapy
- Behaviour Therapy
- Cognitive Therapy
- Cognitive Behaviour Therapy (CBT)
- Person Centered Therapy
- Gestalt Therapy
- Rational Emotive Behaviour Therapy (REBT)
- Family Therapy
- Group Therapy
- Solution Focused therapy
- Narrative Therapy
- Acceptance and Commitment therapy (ACT)
- Body Psychotherapy
- Multicultural therapy
- Choice and Reality Therapy
We will discuss some of the psychotherapies in the next block.
162

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Unit 5 Sexual Disorders and

5.2 WHAT IS NORMAL SEXUALITY?

5.3 SEXUAL RESPONSE CYCLE

Fig. 5.1: The human sexual response

5.4 SEXUAL DISORDERS

Check Your Progress II

Box 5.9 Paraphilic Disorder

5.6 LET US SUM UP

Owen, J. J., Rhoades, G. K., Stanley, S. M., & Fincham, F. D. (2010).

5.8 KEY WORDS

5.9 ANSWERS TO CHECK YOUR PROGRESS

5.11 WEB RESOURCES

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