11.4 SUMMING UP

Gender Dysphoria

• Gender dysphoria is characterized by persistent cross-gender identification that leads to chronic discomfort with one’s natal sex. Symptoms of gender dysphoria often emerge in childhood, but most children diagnosed with the disorder no longer have it when they become adults.
• In children, symptoms of gender dysphoria include cross-dressing and otherwise behaving in ways typical of the other gender, such as engaging in other-gender types of play, choosing other-gender playmates, and even claiming to be the other gender. In adults, symptoms include persistent and extreme discomfort from living publicly as their natal gender, which leads many to live (at least some of the time) as someone of the other gender.
• Some brain areas in adults with gender dysphoria are more similar to the corresponding brain areas of members of their desired gender than they are to those of people who have their natal gender.
• Treatments that target neurological (and other biological) factors include hormone treatments and sex reassignment surgery. Treatments that target psychological factors include psychoeducation, helping the patient choose among gender-related lifestyle options, and problem solving about potential difficulties. Treatments that target social factors include family education, support groups, and group therapy.

Paraphilic Disorders

• Paraphilic disorders are characterized by a predictable sexual arousal pattern regarding “deviant” fantasies, objects, or behaviors. Paraphilic disorders can involve (1) nonconsenting adults or children (exhibitionistic disorder, voyeuristic disorder, frotteuristic disorder, and pedophilic disorder), (2) suffering or humiliating oneself or one’s partner (sexual masochism disorder and sexual sadism disorder), or (3) arousal by nonhuman objects (fetishistic disorder and transvestic disorder). To be diagnosed with a paraphilic disorder, either the person must have acted on these sexual urges and fantasies or these arousal patterns must cause the patient significant distress or impair functioning.

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• Critics of the DSM-5 paraphilic disorders classification note that what is determined to be sexually “deviant” varies across cultures and over time.
• Research shows that paraphilic disorders share similarities with OCD. Additional possible contributing factors include classically conditioned arousal and the Zeigarnik effect.
• Most frequently, men who receive treatment for paraphilic disorders are ordered to do so by the criminal justice system. Treatments that target neurological factors decrease paraphilic behaviors through medication; however, although the behaviors may decrease, the interests often do not. Treatments that target psychological factors are designed to change cognitive distortions about the predatory sexual behaviors.

Sexual Dysfunctions

• Sexual dysfunctions are psychological disorders characterized by problems in the human sexual response cycle. The response cycle traditionally has been regarded as having four phases: excitement, plateau, orgasm, and resolution—but it is now commonly regarded as beginning with sexual attraction and desire.
• Sexual dysfunctions fall into one of four categories: disorders of desire, arousal, orgasm, and pain. To be classified as dysfunctions, they must cause significant distress or problems in the person’s relationships.
• Sexual desire and arousal disorders involve three components: cognitive, emotional, and neurological (and other biological). Problems with any of these components can lead to male hypoactive sexual desire disorder, erectile disorder, or female sexual interest/arousal disorder.
• Sexual orgasmic disorders are characterized by persistent problems with the orgasmic response after experiencing a normal excitement phase and adequate stimulation. DSM-5 includes in this category: female orgasmic disorder, delayed ejaculation, and premature ejaculation.
• Genito-pelvic pain/penetration disorder is characterized by pain with sexual intercourse and occurs only in women.
• Criticisms of the way DSM-5 classifies sexual dysfunction disorders include: (1) The sexual response cycle may not apply equally well to women; (2) the end goal is orgasm, not satisfaction; (3) the criteria rest on a particular definition of normal sexual functioning that doesn’t encompass normal aging.
• Various factors contribute to sexual dysfunctions. Neurological (and other biological) factors include disease, illness, surgery or medications, and the normal aging process.
• Psychological factors include: predisposing factors (such as negative attitudes toward sex), negative conditioning experiences, and a history of sexual abuse; precipitating factors, such as anxiety about sex and distraction because of sexual or nonsexual matters; and maintaining factors, such as worrying about future sexual problems.
• Social factors include the quality of the partners’ relationship, the partner’s sexual functioning, a history of abuse, and sexual mores in the person’s subculture.
• Treatments that target neurological (and other biological) factors are medications for erectile dysfunction and for analogous arousal problems in women.
• Treatments that target psychological factors include psychoeducation, sensate focus exercises, and CBT to counter negative thoughts, beliefs, and behaviors associated with sexual dysfunction.
• Treatments that target social factors address problematic issues in a couple’s relationship as well as teach the couple specific sex-related cognitive or behavioral strategies.
• Treatments that focus on one type of factor for a given patient can create complex feedback loops, which sometimes have unexpected—and perhaps negative—consequences for the couple.