Ebook Pocket handbook of clinical psychiatry (6/E): Part 2

18
SexualDysfunctionandGenderDysphoria

Sexual dysfunctions are an inability to respond to sexual stimulation, or the
experience of pain during the sexual act. It is defined by disturbance in the
subjective sense of pleasure or desire associated with sex, or by the objective
performance.IntheDiagnosticandStatisticalManualofMentalDisorders,fifth
edition(DSM-5),thesexualdysfunctionsincludemalehypoactivesexualdesire
disorder, female sexual interest/arousal disorder, erectile disorder, female
orgasmic disorder, delayed ejaculation, premature (early) ejaculation, genitopelvic pain/penetration disorder, substance/medication-induced sexual
dysfunction, other specified sexual dysfunction, and unspecified sexual
dysfunction.Ifmorethanonedysfunctionexists,theyshouldallbediagnosed.
Sexual dysfunctions can be lifelong or acquired, generalized or situational,
and result from psychological factors, physiologic factors, or combined
factors. As per DSM-5 dysfunction due to a general medical condition,
substance use, or adverse effects of medication should be noted. Sexual
dysfunctionmaybediagnosedinconjunctionwithanotherpsychiatricdisorder
(depressive disorders, anxiety disorders, personality disorders, and
schizophrenia).
I. Desire,Interest,andArousalDisorders
A. Male hypoactive sexual desire disorder. Characterized by a lack or
absence of sexual fantasies and desire for minimum duration of 6
months.Menmayhaveneverexperiencederotic/sexualthoughtsandthe
dysfunction can be lifelong. The prevalence is greatest in the younger
(6%ofmenages18to24)andolder(40%ofmenages66to74)with
only2%aged16to44affectedbythisdisorder.
Patientswithdesireproblemsoftenuseinhibitionofdesiredefensively,
to protect against unconscious fears about sex. Lack of desire can also
result from chronic stress, anxiety, or depression or the use of various
psychotropic drugs and other drugs that depress the central nervous
system(CNS).Insextherapyclinicpopulations,lackofdesireisoneof

themostcommoncomplaintsamongmarriedcouples,withwomenmore


affectedthanmen.
Thediagnosisshouldnotbemadeunlessthelackofdesireisasource
ofdistresstoapatient.SeeTable18-1.
B. Female sexual interest/arousal disorder. The combination of interest
(or desire) and arousal reflects that women do not necessarily move
stepwise from desire to arousal, but experience desire synchronously
with,orevenfollowingfeelingsofarousal.Consequently,womenmay
experience either/or both inability to feel interest or arousal, difficulty
achievingorgasmorexperiencepain.Usualcomplaintsincludedecrease
orpaucityoferoticfeelings,thoughtsandfantasies;adecreasedimpulse
toinitiatesex;adecreasedorabsentreceptivitytopartneroverturesand
aninabilitytorespondtopartnerstimulation.
Table18-1
MaleHypoactiveSexualDesireDisorder
Reducedornosexualappetiteorlibidofor≥6months
Manyfactorssuchasageandcultureshouldinformwhetherthepatientfitswithintheboundsfor
normalsexualdesire

Subjective sense of arousal is poorly correlated with genital
lubrication in both normal and dysfunctional women. A woman
complaining of lack of arousal may lubricate vaginally, but may not
experienceasubjectivesenseofexcitement.Theprevalenceisgenerally
underestimated. In one study of subjectively happily married couples,
33% of women described arousal problems. Difficulty in maintaining
excitement can reflect psychological conflicts (e.g., anxiety, guilt, and
fear) or physiologic changes. Alterations in testosterone, estrogen,
prolactin, and thyroxin levels have been implicated in female sexual

arousal disorder. In addition, medications with antihistaminic or
anticholinergic properties cause a decrease in vaginal lubrication.
Relationship problems are particularly relevant to acquired
interest/arousal disorder. In one study of couples with markedly
decreased sexual interaction, the most prevalent etiology was marital
discord.SeeTable18-2.
C. Maleerectiledisorder.Inlifelongmaleerectiledisorderonehasnever
been able to obtain an erection while in acquired type one has
successfullyachievedpenetrationatsometimeinhissexuallife.
Erectiledisorderisreportedin10%to20%ofallmenandisthechief
complaint of more than 50% of all men treated for sexual disorders.


Lifelong male erectile disorder is rare; it occurs in about 1% of men
younger than age 35. The incidence increases with age and has been
reported around 2% to 8% of the young adult population. The rate
increasesto40%to50%inmenbetweenagesof60and70.
Male erectile disorder can be organic or psychological, or a
combination but in young and middle-aged men the cause is usually
psychological.Ahistoryofspontaneouserections,morningerections,or
good erections with masturbation or with partners other than the usual
one indicates functional impotence. Psychological causes of erectile
dysfunction include a punitive conscience or superego, an inability to
trust, or feelings of inadequacy. Erectile dysfunction also may reflect
relationshipdifficultiesbetweenpartners.SeeTable18-3.
Table18-2
FemaleSexualInterest/ArousalDisorder
Reducedornosexualappetiteorlibidofor≥6months≥3of:
Decreasedinterestinsex
Decreaseinthoughtsaboutsexorimaginativescenarios

Decreasedreceptivitytoandengagementinsex
Decreasedenjoymentofsexualsituations
Decreasedresponsivenesstosexualcues
Decreaseingenitalandnongenitalreactionstosex
Cannotbeasequelaofsevererelationshipdistressorsignificantstressors
Table18-3
ErectileDisorder
Difficultyachievingormaintaininganerection,orinattainingerectilestiffnessthroughoutalmost
allsexualeffortsfor≥6months
Cannotbeasequelaofsevererelationshipdistressorsignificantstressors

II. OrgasmDisorders
A. Female orgasmic disorder. Female orgasmic disorder (anorgasmia or
inhibitedfemaleorgasm)isarecurrentorpersistentdelayinorabsence
of orgasm following a normal sexual excitement phase. In lifelong
femaleorgasmicdisorder,onehasneverexperiencedanorgasmbyany
kind of stimulation while in acquired orgasmic disorder one has
previously experienced at least one orgasm. The disorder is more
commonamongunmarriedwomen.Theestimatedproportionofmarried
women over age 35 who never have achieved orgasm is 5%. The
proportion is higher in unmarried women and younger women. The
overall prevalence of inhibited female orgasm is 30%. Psychological


factorsassociatedwithinhibitedorgasmincludefearsofimpregnationor
rejectionbythesexpartner,hostilitytowardmen,feelingsofguiltabout
sexualimpulses,ormaritalconflicts.SeeTable18-4.
B. Delayedejaculation.Inmaledelayedejaculation(retardedejaculation),
a man achieves ejaculation during coitus with great difficulty, if at all.
The problem occurs mostly during coital activity. Lifelong inhibited

male orgasm usually indicates more severe psychopathology. Acquired
ejaculatory inhibition frequently reflects interpersonal difficulties. The
incidenceislowcomparedtoprematureejaculationandinonegroupof
menwasonly3.8%.Ageneralprevalenceof5%hasbeenreportedbut
morerecentlyincreasedrateshavebeenseen.Thishasbeenattributedto
the increasing use of antidepressants like selective serotonin reuptake
inhibitors(SSRIs),whichcausedelayedorgasm.SeeTable18-5.
C. Premature (early) ejaculation. In premature ejaculation, men
persistently or recurrently achieve orgasm and ejaculation before they
wishto.Thediagnosisismadewhenamanregularlyejaculatesbefore
orwithinapproximately1minuteafterpenetration.Itismoreprevalent
amongyoungmen,menwithanewpartner,andcollege-educatedmen
thanamongmenwithlesseducation;theproblemwiththelattergroupis
thought to be related to concern for partner satisfaction. Premature
ejaculation is the chief complaint of 35% to 40% of men treated for
sexualdisorders.
Table18-4
FemaleOrgasmicDisorder
Reductioninfrequency,immediacy,orintensityoforgasm
Cannotbeasequelaofsevererelationshipdistressorsignificantstressors
Table18-5
DelayedEjaculation
Increaseinlatencyordecreaseinregularityofejaculationduringalmostallsexualeffortsfor≥6
months
Cannotbeasequelaofsevererelationshipdistressorsignificantstressors

Difficulty in ejaculatory control may be associated with anxiety
regarding the sex act and with unconscious fears about the vagina. It
may also be the result of conditioning if the man’s early sexual
experiencesoccurredinsituationsinwhichdiscoverywouldhavebeen

embarrassing.Astressfulmarriageexacerbatesthedisorder.


Behavioraltechniquesareusedintreatment.However,asubgroupof
premature ejaculators may be biologically predisposed; they are more
vulnerable to sympathetic stimulation or they have a shorter
bulbocavernosus reflex nerve latency time, and they should be treated
pharmacologicallywithSSRIsorotherantidepressants.Asideeffectof
thesedrugsistheinhibitionofejaculation.
The developmental background and the psychodynamics found in
prematureejaculationandinerectiledisorderaresimilar.SeeTable186.
III. SexualPainDisorders
A. Genito-pelvic pain/penetration disorder. In DSM-5, this disorder
referstooneormoreofthefollowingcomplaints,ofwhichanytwoor
more may occur together: difficulty having intercourse; genito-pelvic
pain;fearofpainorpenetration;andtensionofthepelvicfloormuscles.
Previously, these were diagnosed as dyspareunia or vaginismus and
could coexist and lead to fear of pain with sex. These diagnoses are
categorizedintoonediagnosticcategorybutforthepurposesofclinical
discussionthedistinctcategoriesofdyspareuniaandvaginismusremain
clinicallyuseful.SeeTable18-7.
1. Dyspareunia. Dyspareunia is recurrent or persistent genital pain
occurringbefore,during,orafterintercourse.Dyspareuniaisrelated
to vaginismus and repeated episodes of vaginismus can lead to
dyspareunia. DSM-5 cites that 15% of women in North America
reportrecurrentpainduringintercourse.
Table18-6
Premature(Early)Ejaculation
Undesiredejaculationduringthefirstminuteafter(vaginal)penetration
Ejaculationoccursprematurelyduringalmostallsexualencounters

(Durationcriteriadonotexistforotherpenetrationsites.)
Table18-7
Genito-PelvicPain/PenetrationDisorder
Problemswithatleastoneof:
Vaginalpenetration
Extremepelvic/vaginalpainduringpenetrationattempts
Anxietyaboutsuchpain
Pelvicmuscleclenchingduringpenetration
ThoughGPPshouldcausedistress,itcannotbeasequelaofsevererelationshipdistressor
significantstressors


Chronic pelvic pain is a common complaint in women with a
history of rape or childhood sexual abuse. Painful coitus can result
from tension and anxiety and makes intercourse unpleasant or
unbearable. Dyspareunia is uncommon in men and is usually
associated with a medical condition (e.g., Peyronie’s disease).
Dyspareuniamaypresentasanyofthefourcomplaintslistedunder
genito-pelvic pain/penetration disorder and should be diagnosed as
genito-pelvicpain/penetrationdisorder.
2. Vaginismus.Definedasaconstrictionoftheouterthirdofthevagina
due to involuntary pelvic floor muscle tightening or spasm,
vaginismusinterfereswithpenileinsertionandintercourse.
Vaginismusmaybecomplete,thatisnopenetrationofthevaginais
possible.Inalesssevereform,painmakespenetrationdifficult,but
notimpossible.
It mostly afflicts highly educated women and of high
socioeconomicgroups.Asexualtrauma,suchasrape,orunpleasant
first coital experience may cause vaginismus. A strict religious
upbringing in which sex is associated with sin is frequent in these

patients.
IV. SexualDysfunctionDuetoaGeneralMedicalCondition
A. Maleerectiledisorderduetoageneralmedicalcondition.Statistics
indicatethat20%to50%ofmenwitherectiledisorderhaveanorganic
basisforthedisorder.Aphysiologicetiologyislikelyinmenolderthan
50 and the most likely cause in men older than age 60. The organic
causesofmaleerectiledisorderarelistedinTable18-8.
Following procedures may help differentiate organically caused
erectiledisorderfromfunctionalerectiledisorder.
1. Monitoring nocturnal penile tumescence (erections during rapid eye
movementsleep)
2. Monitoringtumescencewithastraingauge
3. Measuringbloodpressureinthepeniswithapenileplethysmograph
Other diagnostic include glucose tolerance tests, plasma hormone
assays,liverandthyroidfunctiontests,prolactinandfollicle-stimulating
hormone(FHS)determinations,andcystometricexaminations.
Table18-8
DiseasesandOtherMedicalConditionsImplicatedinMaleErectileDisorder
Infectiousandparasiticdiseases


Elephantiasis
Mumps
Cardiovasculardiseasea
Atheroscleroticdisease
Aorticaneurysm
Leriche’ssyndrome
Cardiacfailure
Renalandurologicdisorders
Peyronie’sdisease

Chronicrenalfailure
Hydroceleandvaricocele
Hepaticdisorders
Cirrhosis(usuallyassociatedwithalcoholdependence)
Pulmonarydisorders
Respiratoryfailure
Genetics
Klinefelter’ssyndrome
Congenitalpenilevascularandstructuralabnormalities
Nutritionaldisorders
Malnutrition
Vitamindeficiencies
Obesity
Endocrinedisordersa
Diabetesmellitus
Acromegaly
Addison’sdisease
Chromophobeadenoma
Adrenalneoplasia
Myxedema
Hyperthyroidism
Neurologicdisorders
Multiplesclerosis
Transversemyelitis
Parkinson’sdisease
Temporallobeepilepsy
Traumaticandneoplasticspinalcorddiseasesa
Centralnervoussystemtumor
Amyotrophiclateralsclerosis
Peripheralneuropathy

Generalparesis
Tabesdorsalis
Pharmacologicfactors
Alcoholandotherdependence-inducingsubstances(heroin,methadone,morphine,cocaine,
amphetamines,andbarbiturates)
Prescribeddrugs(psychotropicdrugs,antihypertensivedrugs,estrogens,andantiandrogens)
Poisoning
Lead(plumbism)
Herbicides
Surgicalproceduresa
Perinealprostatectomy
Abdominal-perinealcolonresection
Sympathectomy(frequentlyinterfereswithejaculation)


Aortoiliacsurgery
Radicalcystectomy
Retroperitoneallymphadenectomy
Miscellaneous
Radiationtherapy
Pelvicfracture
Anyseveresystemicdiseaseordebilitatingcondition
aIntheUnitedStatesanestimated2millionmenareimpotentbecausetheyhavediabetes

mellitus;anadditional300,000areimpotentbecauseofotherendocrinediseases;1.5million
areimpotentasaresultofvasculardisease;180,000becauseofmultiplesclerosis;400,000
becauseoftraumasandfracturesleadingtopelvicfracturesorspinalcordinjuries;andanother
650,000areimpotentasaresultofradicalsurgery,includingprostatectomies,colostomies,and
cystectomies.

B. Dyspareunia due to a general medical condition. An estimated 30%
ofallsurgicalproceduresonthefemalegenitalarearesultintemporary
dyspareunia.Inaddition,30%to40%ofwomenwiththecomplaintwho
are seen in sex therapy clinics have pelvic pathology. Organic
abnormalitiesleadingtodyspareuniaandvaginismusincludeirritatedor
infected hymenal remnants, episiotomy scars, Bartholin’s gland
infection, various forms of vaginitis and cervicitis, endometriosis, and
adenomyosis. Postcoital pain has been reported by women with
myomata, endometriosis, and adenomyosis, and is attributed to the
uterine contractions during orgasm. Postmenopausal women may have
dyspareuniaresultingfromthinningofthevaginalmucosaandreduced
lubrication.
Two conditions not readily apparent on physical examination that
producedyspareuniaarevulvarvestibulitisandinterstitialcystitis.
Table18-9
NeurophysiologyofSexualDysfunction

Erection

5DA HT NE ACh ClinicalCorrelation
↑
M
Antipsychoticsmayleadtoerectiledysfunction(DAblock):DA
agonistsmayleadtoenhancederectionandlibido;priapism
withtrazodone(α1,block);β-blockersmayleadtoimpotence

Ejaculation
M
α-Blockers(tricyclicdrugs,MAOls,thioridazine)mayleadto
and

impairedejaculation;5-HTagentsmayinhibitorgasm
orgasm
↑,facilities;↓,inhibitsordecreases;±,some;ACh,acetylcholine;DA,dopamine;5-HT,
serotonin;M,modulates;NE,norepinephrine;minimal.
ReprintedwithpermissionfromSegravesR.PsychiatricTimes.1990.

C. Male hypoactive sexual desire disorder and female interest/arousal


disorderduetoageneralmedicalcondition.Sexualdesirecommonly
decreases after major illness or surgery, particularly when the body
image is affected after such procedures as mastectomy, ileostomy,
hysterectomy,andprostatectomy.Insomecases,biochemicalcorrelates
are associated with hypoactive sexual desire disorder (Table 18-9).
Drugs that depress the CNS or decrease testosterone production can
decreasedesire.
D. Other male sexual dysfunction due to a general medical condition.
Delayed ejaculation can have physiologic causes and can occur after
surgeryonthegenitourinarytract,suchasprostatectomy.Itmayalsobe
associated with Parkinson’s disease and other neurologic disorders
involving the lumbar or sacral sections of the spinal cord. The
antihypertensive drug guanethidine monosulfate (Ismelin), methyldopa
(Aldomet),thephenothiazines,thetricyclicdrugs,andtheSSRIs,among
others,havebeenimplicatedinretardedejaculation(Table18-10).
E. Otherfemalesexualdysfunctionduetoageneralmedicalcondition.
Some medical conditions—specifically, endocrine diseases such as
hypothyroidism, diabetes mellitus, and primary hyperprolactinemia—
canaffectawoman’sabilitytohaveorgasms.
F. Substance/medication-induced sexual dysfunction. The diagnosis of
substance-induced sexual dysfunction is used when evidence of

substance intoxication or withdrawal is apparent from the history,
physicalexamination,orlaboratoryfindings.Thedisturbanceinsexual
functionmustbepredominantintheclinicalpicture.SeeTable18-11.In
general, sexual function is negatively affected by serotonergic agents,
dopamineantagonists,drugsthatincreaseprolactin,anddrugsthataffect
the autonomic nervous system. With commonly abused substances,
dysfunctionoccurswithinamonthofsignificantsubstanceintoxication
orwithdrawal.Insmalldoses,somesubstances(e.g.,amphetamine)may
enhance sexual performance, but abuse impairs erectile, orgasmic, and
ejaculatorycapacities.
Oral contraceptives are reported to decrease libido in some women,
andsomedrugswithanticholinergicsideeffectsmayimpairarousalas
wellasorgasm.Benzodiazepineshavebeenreportedtodecreaselibido,
but in some patients the diminution of anxiety caused by those drugs
enhances sexual function. Both increase and decrease in libido have
been reported with psychoactive agents. Alcohol may foster the
initiation of sexual activity by removing inhibition, but it also impairs
performance. Sexual dysfunction associated with the use of a drug


disappears when the drug is discontinued. Table 18-12 lists psychiatric
medicationsthatmayinhibitfemaleorgasm.
Table18-10
PharmacologicAgentsImplicatedinMaleSexualDysfunctions
Drug
Psychiatricdrugs
Selectiveserotoninreuptakeinhibitorsa
Citalopram(Celexa)
Fluoxetine(Prozac)
Paroxetine(Paxil)

Sertraline(Zoloft)
Cyclicdrugs
Imipramine(Tofranil)
Protriptyline(Vivactil)
Desipramine(Pertofrane)
Clomipramine(Anafranil)
Amitriptyline(Elavil)
Monoamineoxidaseinhibitors
Tranylcypromine(Parnate)
Phenelzine(Nardil)
Pargyline(Eutonyl)
Isocarboxazid(Marplan)
Othermood-activedrugs
Lithium(Eskalith)
Amphetamines
Trazodone(Desyrel)b
Venlafaxine(Effexor)
Antipsychoticsc
Fluphenazine(Prolixin)
Thioridazine(Mellaril)
Chlorprothixene(Taractan)
Mesoridazine(Serentil)
Perphenazine(Trilafon)
Trifluoperazine(Stelazine)
Reserpine(Serpasil)
Haloperidol(Haldol)
Antianxietyagentd
Chlordiazepoxide(Librium)
Antihypertensivedrugs
Clonidine(Catapres)

Methyldopa(Aldomet)
Spironolactone(Aldactone)
Hydrochlorothiazide(Hydrodiuril)
Guanethidine(Ismelin)

ImpairsErection

ImpairsEjaculation

–
–
–
–

+
+
+
+

+
+
+
+
+

+
+
+
+
+

+
+
–
–



+
+
–
–



+
+
–
–
–
–
+
–



+
+
+

+
–
+

+
+
+
+
+
+
+

–
+
+
+
+
+

+

+
–
–
+


Commonlyabusedsubstances
Alcohol
Barbiturates

Cannabis
Cocaine
Heroin
Methadone
Morphine

+
+
+
+
+
+
+

+
+
–
+
+
–
+

Miscellaneousdrugs
Antiparkinsonianagents
Clofibrate(Atromid-S)
Digoxin(Lanoxin)
Glutethimide(Doriden)
Indomethacin(Indocin)
Phentolamine(Regitine)
Propranolol(Inderal)

+
+
+
+
+
–
+

+
–
–
+
–
+
–

aSSRIsalsoimpairdesire.
bTrazodonehasbeencausativeinsomecasesofpriapism.
cImpairmentofsexualfunctionislesslikelywithatypicalantipsychotics.Priapismhas

occasionallyoccurredinassociationwiththeuseofantipsychotics.
dBenzodiazepineshavebeenreportedtodecreaselibido,butinsomepatientsthediminutionof
anxietycausedbythosedrugsenhancessexualfunction.
Table18-11
Substance/Medication-InducedSexualDysfunction
Adistressingchangeinsexualfunctionduringorsoonafterintoxicationoforwithdrawalfroma
substance/medicationthatisknowntoproducesuchsymptoms.
(Redflagsincludedeliriumandsymptomsofthesexualdysfunctionoutsideoftheinfluenceof
thesubstance/medication.)

G. Pharmacologic agents implicated in sexual dysfunction. Almost
every pharmacologic agent, particularly those used in psychiatry, has
beenassociatedwithaneffectonsexuality.Theeffectsofpsychoactive
drugsaredetailedlaterinthissection.Foradetailedlistofmedication
thatimpactsexualfunctioning,seeTable18-13.
1. Antipsychotic drugs. Most antipsychotic drugs are dopamine
receptor antagonists that also block adrenergic and cholinergic
receptors,thusaccountingfortheadversesexualeffects.
2. Antidepressantdrugs. The tricyclic and tetracyclic antidepressants
have anticholinergic effects that interfere with erection and delay
ejaculation.Clomipramine(Anafranil)hasbeenreportedtoincrease
sex drive in some persons. Selegiline (Deprenyl), a selective MAO


type B (MAOB) inhibitor, and bupropion (Wellbutrin) also increase
sex drive. SSRIs and SNRIs lower the sex drive and difficulty
reachingorgasmoccurinbothsexes.
Table18-12
SomePsychiatricDrugsImplementedinInhibitedFemaleOrgasma
Tricyclicantidepressants
Imipramine(Tofranil)
Clomipramine(Anafranil)
Nortriptyline(Aventyl)
Monoamineoxidaseinhibitors
Tranylcypromine(Parnate)
Phenelzine(Nardil)
Isocarboxazid(Marplan)
Dopaminereceptorantagonists
Thioridazine(Mellaril)

Trifluoperazine(Stelazine)
Selectiveserotoninreuptakeinhibitors
Fluoxetine(Prozac)
Paroxetine(Paxil)
Sertraline(Zoloft)
Fluvoxamine(Luvox)
Citalopram(Celexa)
aTheinterrelationbetweenfemalesexualdysfunctionandpharmacologicagentshasbeenless

extensivelyevaluatedthanmalereactions.Oralcontraceptivesarereportedtodecreaselibido
insomewomen,andsomedrugswithanticholinergicsideeffectsmayimpairarousalaswellas
orgasm.Prolongeduseoforalcontraceptivesmayalsocausephysiologicmenopausal-like
changesresultingingenito-pelvicpain/penetrationdisorder.Benzodiazepineshavebeen
reportedtodecreaselibido,butinsomepatientsthediminutionofanxietycausedbythose
drugsenhancessexualfunction.Bothincreaseanddecreaseinlibidohavebeenreportedwith
psychoactiveagents.Itisdifficulttoseparatethoseeffectsfromtheunderlyingconditionorfrom
improvementofthecondition.Sexualdysfunctionassociatedwiththeuseofadrugdisappears
whenuseofthedrugisdiscontinued.
Table18-13
SomePharmacologicAgentsImplicatedinSexualDysfunctions
Drug
Psychiatricdrugs
Cyclicdrugsa
Imipramine(Tofranil)
Protriptyline(Vivactil)
Desipramine(Pertofrane)
Clomipramine(Anafranil)
Amitriptyline(Elavil)
Trazodone(Desyrel)b

ImpairsErection

ImpairsEjaculation

+
+
+
+
+
–

+
+
+
+
+
–


Monoamineoxidaseinhibitors
Tranylcypromine(Parnate)
Phenelzine(Nardil)
Pargyline(Eutonyl)
Isocarboxazid(Marplan)

+
+
–
–

+
+
+

Othermood-activedrugs
Lithium(Eskalith)
Amphetamines
Fluoxetine(Prozac)e

+
+
–


+
+

Antipsychoticsc
Fluphenazine(Prolixin)
Thioridazine(Mellaril)
Chlorprothixene(Taractan)
Mesoridazine(Serentil)
Perphenazine(Trilafon)
Trifluoperazine(Stelazine)
Reserpine(Serpasil)
Haloperidol(Haldol)

+
+

–
–
–
–
+
–

Antianxietyagentd
Chlordiazepoxide(Librium)

–

+

Antihypertensivedrugs
Clonidine(Catapres)
Methyldopa(Aldomet)
Spironolactone(Aldactone)
Hydrochlorothiazide
Guanethidine(Ismelin)

+
+
+
+
+


+
–

–
+

Commonlyabusedsubstances
Alcohol
Barbiturates
Cannabis
Cocaine
Heroin
Methadone
Morphine

+
+
+
+
+
+
+

+
+
–
+
+
–
+

Miscellaneousdrugs
Antiparkinsonianagents

Clofibrate(Atromid-S)
Digoxin(Lanoxin)
Glutethimide(Doriden)
Indomethacin(Indocin)
Phentolamine(Regitine)
Propranolol(Inderal)

+
+
+
+
+
–
+

+
–
–
+
–
+
–


+
+
+
+
+
+

+

aTheincidenceofmaleerectiledisorderassociatedwiththeuseoftricyclicdrugsislow.


bTrazodonehasbeencausativeinsomecasesofpriapism.
cImpairmentofsexualfunctionisnotacommoncomplicationoftheuseofantipsychotics.

Priapismhasoccasionallyoccurredinassociationwiththeuseofantipsychotics.
dBenzodiazepineshavebeenreportedtodecreaselibido,butinsomepatientsthediminutionof
anxietycausedbythosedrugsenhancessexualfunction.
eAllSSRIscanproducesexualdysfunction,morecommonly,inmen.

a. Lithium. Lithium (Eskalith) regulates mood and, in the manic
state, may reduce hypersexuality, possibly by a dopamine
antagonist activity. In some patients, impaired erection has been
reported.
b. Sympathomimetics. Psychostimulants raise the plasma levels of
norepinephrine and dopamine. Libido is increased; however, with
prolongeduse,menmayexperiencealossofdesireanderections.
c. a-Adrenergic and β-adrenergic receptor antagonists. αAdrenergic and β-adrenergic receptor antagonists diminish tonic
sympatheticnerveoutflowfromvasomotorcentersinthebrainand
that can cause impotence, decrease the volume of ejaculate, and
produceretrogradeejaculation.
3. Anticholinergics. The anticholinergics block cholinergic receptors
andcausedrynessofthemucousmembranes(includingthoseofthe
vagina) and erectile disorder. However, amantadine may reverse
SSRI-inducedorgasmicdysfunctionthroughitsdopaminergiceffect.
4. Antihistamines. Drugs such as diphenhydramine (Benadryl) may
inhibitsexualfunction.Cyproheptadine,althoughanantihistamine,is

a serotonin antagonist and reverses sexual adverse effects produced
bySSRIs.
5. Antianxiety agents. Benzodiazepines diminish anxiety, and as a
resulttheyimprovesexualfunctioninpersonsinhibitedbyanxiety.
6. Alcohol. Alcohol can produce erectile disorders in men but
paradoxically increase testosterone levels in women. This may
account for women to have increased libido after drinking small
amountsofalcohol.
7. Opioids. Opioids, such as heroin, have adverse sexual effects, such
as erectile failure and decreased libido. The alteration of
consciousness may enhance the sexual experience in occasional
users.
V. Treatment
Treatmentfocusesontheexplorationofunconsciousconflicts,motivation,


fantasy, and various interpersonal difficulties. Methods that have proved
effectivesinglyorincombinationinclude(1)traininginbehavioral–sexual
skills, (2) systematic desensitization, (3) directive marital therapy, (4)
psychodynamic approaches, (5) group therapy, (6) pharmacotherapy, (7)
surgery, and (8) hypnotherapy. Evaluation and treatment must address the
possibilityofaccompanyingpersonalitydisordersandphysicalconditions.
Theadditionofbehavioraltechniquesisoftennecessarytocurethesexual
problem.
A. Dual-sex therapy. The theoretical basis of dual-sex therapy is the
conceptofthemaritalunitordyadastheobjectoftherapy.Indual-sex
therapy,treatmentisbasedonaconceptthatthecouplemustbetreated
when a dysfunctional person is in a relationship. There is a roundtable
sessioninwhichamaleandfemaletherapyteamclarifies,discusses,and
works through problems with the couple and open communication

betweenthepartnersisurged.
B. Specifictechniquesandexercises
Varioustechniquesareusedtotreatthevarioussexualdisorders.
1. Vaginismus. The woman is advised to dilate her vaginal opening
withherfingersorwithdilators.
2. Prematureejaculation. The squeeze technique is used to raise the
threshold of penile excitability. The patient or his partner forcibly
squeezes the coronal ridge of the glans at the first sensation of
impending ejaculation. The erection is diminished and ejaculation
inhibited. A variation is the stop–start technique. Stimulation is
stoppedasexcitementincreases,butnosqueezeisused.
3. Maleerectiledisorder.Themanissometimestoldtomasturbateto
demonstratethatfullerectionandejaculationarepossible.
4. Female orgasmic disorder (primary anorgasmia). The woman is
instructed to masturbate, sometimes with the use of a vibrator. The
useoffantasyisencouraged.
5. Retarded ejaculation. It is managed by extravaginal ejaculation
initially and gradual vaginal entry after stimulation to the point of
nearejaculation.
C. Hypnotherapy. Hypnotherapists focus specifically on the anxietyproducing situation—that is, the sexual interaction that results in
dysfunction. The successful use of hypnosis enables patients to gain
control over the symptom that has been lowering self-esteem and
disrupting psychological homeostasis. The focus of treatment is on


symptom removal and attitude alteration. Hypnosis may be added to a
basic individual psychotherapy program to accelerate the effects of
psychotherapeuticintervention.
D. Behaviortherapy.Thebehaviortherapistenablesthepatienttomaster
the anxiety through a standard program of systematic desensitization,

which is designed to inhibit the learned anxious response by
encouragingbehaviorsantitheticaltoanxiety.Thepatientfirstdealswith
theleastanxiety-producingsituationinfantasyandprogressesbysteps
to the most anxiety-producing situation. Medication, hypnosis, and
special training in deep muscle relaxation are sometimes used to help
with the initial mastery of anxiety. Sexual exercises may be prescribed
starting with those activities that have proved most pleasurable and
successfulinthepast.
E. Mindfulness.Mindfulnessisacognitivetechniquethathasbeenhelpful
inthetreatmentofsexualdysfunction.Thepatientisdirectedtofocuson
the moment and maintain an awareness of sensations—visual, tactile,
auditory,andolfactory—thatheorsheexperiencesinthemoment.
F. Grouptherapy.Atherapygroupprovidesastrongsupportsystemfora
patient who feels ashamed, anxious, or guilty about a particular sexual
problem. It is a useful forum in which to counteract sexual myths,
correct misconceptions, and provide accurate information about sexual
anatomy,physiology,andvarietiesofbehavior.Grouptherapycanbean
adjunct to other forms of therapy or the prime mode of treatment.
Techniques, such as role playing and psychodrama, may be used in
treatment.
Table18-14
PharmacokineticsofthePDE-5Inhibitors

Sildenafil100mg Vardenafil20mg Tadalafil20mg
Maximumconcentration
450ng/mL
20.9ng/mL
378ng/mL
Timetomaximumconcentration
1.0hours

0.7hours
2.0hours
Half-life
4hours
3.9hours
17.5hours
FromArnoldLM.Vardenafil&Tadalafil:Optionsforerectiledysfunction.CurrPsychiatr.
2004;3(2):46.

G. Analyticallyorientedsextherapy.Oneofthemosteffectivetreatment
modalities is the integration of sex therapy (training in behavioral–
sexual skills) with psychodynamic and psychoanalytically oriented
psychotherapy. Psychodynamic conceptualizations are added to
behavioraltechniquesforthetreatmentofpatients.


H. Biologic treatments. Biologic treatments, including pharmacotherapy,
surgery, and mechanical devices, are used to treat specific cases of
sexual disorder. Most of the recent advances involve male sexual
dysfunction.Currentstudiesareunderwaytotestbiologictreatmentof
sexualdysfunctioninwomen.
I. Pharmacotherapy.Mostpharmacologictreatmentsinvolvemalesexual
dysfunctions.Studiesarebeingconductedtotesttheuseofdrugstotreat
women. Pharmacotherapy may be used to treat sexual disorders of
physiologic, psychological, or mixed causes. In the latter two cases,
pharmacologic treatment is usually used in addition to a form of
psychotherapy.
J. Treatmentoferectiledisorderandprematureejaculation.Themajor
new medications to treat sexual dysfunction are sildenafil (Viagra) and
its congeners (Table 18-14); oral phentolamine (Vasomax); alprostadil

(Caverject), and injectable medications; papaverine, prostaglandin E1,
phentolamine,orsomecombinationofthese(Edex);andatransurethral
alprostadil(MUSE),allusedtotreaterectiledisorder.
CLINICALHINT:
Whenprescribinganyofthesedrugs,besuretoexplaintothepatientthat
thepilldoesnotproduceanerectionspontaneously.Sexualstimulationis
necessaryifanerectionistooccur.
Sildenafil (Viagra), a nitric oxide enhancer, facilitates the inflow of
blood to the penis necessary for an erection for about 4 hours. The
medicationdoesnotworkintheabsenceofsexualstimulation.Itsuseis
contraindicated for people taking organic nitrates. New nitric oxide
enhancers are vardenafil (Levitra) and tadalafil (Cialis). Tadalafil is
effectiveforupto36hours.
Othermedicationsactasvasodilatorsinthepenis.Theyincludeoral
prostaglandin (Vasomax); alprostadil (Caverject), an injectable
phentolamine; and a transurethral alprostadil suppository (MUSE). αAdrenergic
agents
such
as
methylphenidate
(Ritalin),
dextroamphetamine (Dexedrine), and yohimbine (Yocon) are also used
to treat erectile disorder. SSRIs and heterocyclic antidepressants
alleviateprematureejaculationbecauseoftheirsideeffectofinhibiting
orgasm.
Flibanserin,adrugtoincreasedesireinwomenwasapprovedforuse


in2015.SoldunderthetradenameAddyi,isusedforthetreatmentof
premenopausalwomenwithhypoactivesexualdesiredisorder.Adverse

events include dizziness, nausea, fatigue, day-time sleepiness, and
interruptednight-timesleep.Drinkingalcoholwillcauseseveredropin
bloodpressure.Becauseoflimitedpostmarketingdata,cliniciansshould
becautiousaboutprescribingthedrug.
K. Treatment of sexual aversion disorder. Cyclic antidepressants and
SSRIsareusedifpeoplewiththisdysfunctionareconsideredphobicof
thegenitalia.
L. Hormonetherapy.Androgensincreasethe sex drivein womenandin
men with low testosterone concentrations. Women may experience
virilizingeffects,someofwhichareirreversible(e.g.,deepeningofthe
voice).Inmen,prolongeduseof androgens produceshypertensionand
prostaticenlargement.
Estrogensusemaycausedecreasedlibido;insuchcases,acombined
preparationofestrogenandtestosteronehasbeenusedeffectively.
M. Antiandrogens and antiestrogens. Estrogens and progesterone are
antiandrogensthathavebeenusedtotreatcompulsivesexualbehaviorin
men,usuallyinsexoffenders.
VI. OtherSpecifiedSexualDysfunctions
Many sexual disorders are not classifiable as sexual dysfunctions or as
paraphilias. These unclassified disorders are rare, poorly documented, not
easily classified, or not specifically described in DSM-5. Never-the-less
theyaresyndromesthattherapistshaveseenclinically.SeeTable18-15.
A. Postcoital dysphoria. Occurs during the resolution phase of sexual
activity,whenpersonsnormallyexperienceasenseofgeneralwell-being
and muscular and psychological relaxation. Some persons become
depressed,tense,anxious,andirritable,andshowpsychomotoragitation.
They often want to get away from their partners and may become
verballyorevenphysicallyabusiveandismorecommoninmen.
B. Coupleproblems.Attimes,acomplaintarisesfromthespousalunitor
thecouple,ratherthanfromanindividualdysfunction.Forexample,one

partnermayprefermorningsex,buttheotherfunctionsmorereadilyat
night,orthepartnershaveunequalfrequenciesofdesire.
Table18-15
OtherSpecifiedSexualDysfunction
Sexualdysfunctionnotmeetingfullcriteria(e.g.,sexualaversion)


Table18-16
SignsofSexualAddiction
1.
2.
3.
4.
5.
6.
7.
8.

Out-of-controlbehavior
Severeadverseconsequences(medical,legal,interpersonal)duetosexualbehavior
Persistentpursuitofself-destructiveorhigh-risksexualbehavior
Repeatedattemptstolimitorstopsexualbehavior
Sexualobsessionandfantasyasaprimarycopingmechanism
Theneedforincreasingamountsofsexualactivity
Severemoodchangesrelatedtosexualactivity(e.g.,depression,euphoria)
Inordinateamountoftimespentinobtainingsex,beingsexual,orrecoveringfromsexual
experience
9. Interferenceofsexualbehaviorinsocial,occupational,orrecreationalactivities
DatafromCarnesP.Don’tCallItLove.NewYork:BantamBooks;1991.

C. Bodyimageproblems.Some persons areashamed oftheirbodies and
insistonsexonlyduringtotaldarkness,notallowcertainbodypartsto
be seen or touched, or seek unnecessary operative procedures to deal
withtheirimaginedinadequacies.Bodydysmorphicdisordershouldbe
ruledout.
D. Sex addiction and compulsivity. The concept of sex addiction
developed over the last two decades to refer to persons who
compulsivelyseekoutsexualexperiencesandwhosebehaviorbecomes
impairediftheyareunabletogratifytheirsexualimpulses.
In DSM-5, the terms sex addiction or compulsive sexuality are not
used,norisitadisorderthatisuniversallyrecognizedoraccepted.Such
persons show repeated and increasingly frequent attempts to have a
sexual experience, deprivation of which gives rise to symptoms of
distress.
ThesignsofsexualaddictionarelistedinTable18-16.
E. Typesofbehavioralpatterns.Theparaphiliasconstitutethebehavioral
patterns most often found in the sex addict. The essential features of a
paraphilia are recurrent, intense sexual urges or behaviors, including
exhibitionism, fetishism, frotteurism, sadomasochism, cross-dressing,
voyeurism, and pedophilia. Paraphilias are associated with clinically
significant distress and almost invariably interfere with interpersonal
relationships,andtheyoftenleadtolegalcomplications.
1. Distressaboutsexualorientation.Distressaboutsexualorientation
ischaracterizedbydissatisfactionwithsexualarousalpatterns,andit
isusuallyappliedtodissatisfactionwithhomosexualarousalpatterns,
adesiretoincreaseheterosexualarousal,andstrongnegativefeelings
aboutbeinghomosexual.


2.

3.

4.

5.

6.

Treatmentofsexualorientationdistressalsoknownasconversion
orreparativetherapyiscontroversial.
Another and more prevalent style of intervention is directed at
enabling persons with persistent and marked distress about sexual
orientation to live comfortably with homosexuality without shame,
guilt,anxiety,ordepression.Gaycounselingcentersareengagedwith
patients in such treatment programs. The American Psychiatric
Associationopposes conversion therapyon two grounds:itis based
ontheassumptionthathomosexualityisadiseaseandthatithasnot
beenprovedtowork.Opponentsofconversiontherapyconsideritto
benotonlyunethicalbutillegalandsomegroupsadvocatelawsthat
prohibit therapists fromengaging in oradvocatingsuch approaches.
Overall,conversiontherapyhasbeendiscredited.
Persistent genital arousal disorder. Persistent genital arousal
disorder(PGAD)haspreviouslybeencalledpersistentsexualarousal
syndrome. It has been diagnosed in women who complain of a
continualfeelingofsexualarousal,whichisuncomfortable,demands
release,andinterfereswithlifepleasuresandactivities.Thesewomen
masturbate frequently, sometimes incessantly, because climax
provides relief. However, the relief is temporary and the sense of
arousal returns rapidly and remains. The sense of arousal in these

cases is neither pleasurable nor exciting. One case of attempted
suicide has been reported with this syndrome. There is some
speculationthatthisdisorderisduetonervedamageoranomaly,but
theetiologyisunknown.
Femaleprematureorgasm.Acaseofmultiplespontaneousorgasms
without sexual stimulation was seen in a woman; the cause was an
epileptogenic focus in the temporal lobe. Instances have been
reported of women taking antidepressants (e.g., fluoxetine and
clomipramine) who experience spontaneous orgasm associated with
yawning.
Postcoitalheadache.Postcoitalheadache,characterizedbyheadache
immediately after coitus, may last for several hours. It is usually
describedasthrobbingandislocalizedintheoccipitalorfrontalarea.
Thecauseisunknown.
Orgasmicanhedonia.Orgasmicanhedoniaisaconditioninwhicha
person has no physical sensation of orgasm, even though the
physiologiccomponent(e.g.,ejaculation)remainsintact.
Masturbatory pain. Persons may experience pain during


masturbation. Organic causes should always be ruled out; a small
vaginal tear or early Peyronie’s disease can produce a painful
sensation. The condition should be differentiated from compulsive
masturbation.
VII. GenderDysphoria
A. Introduction.Thetermgenderdysphoriareferstothosepersonswitha
marked incongruence between their experienced or expressed gender
andtheonetheywereassignedatbirth.
Thetermgenderidentityreferstothesenseonehasofbeingmaleor
female, which corresponds most often to the person’s anatomical sex.

Persons with gender dysphoria express their discontent with their
assigned sex as a desire to have the body of the other sex or to be
regardedsociallyasapersonoftheothersex.
The term transgender is a general term used to refer to those who
identify with a gender different from the one they were born with
(sometimesreferredtoastheirassignedgender).
B. Genderidentitydisorders.Agroupofdisordersthathaveastheirmain
symptomapersistentpreferencefortheroleoftheoppositesexandthe
feelingthatonewasbornintothewrongsex.
People with disordered gender identity try to live as or pass as
members of the opposite sex. Transsexuals want biologic treatment
(surgery, hormones) to change their biologic sex and acquire the
anatomiccharacteristicsoftheoppositesex.Thedisordersmaycoexist
withotherpathologyorbecircumscribed,withpatientsfunctioningably
inmanyareasoftheirlives.
C. Diagnosis,signs,andsymptoms
1. Children. Gender dysphoria in children is incongruence between
expressed and assigned gender, with the most important criterion
beingadesiretobeanothergenderorinsistencethatoneisanother
gender.Manychildrenwithgenderdysphoriapreferclothingtypical
ofanothergender,preferentiallychooseplaymatesofanothergender,
enjoygamesandtoysassociatedwithanothergender,andtakeonthe
rolesofanothergenderduringplay.Childrenmayexpressadesireto
havedifferentgenitals,statethattheirgenitalsaregoingtochange,or
urinateintheposition(standingorsitting)typicalofanothergender.
2. Adolescents and adults. Adolescents and adults diagnosed with
genderdysphoriamustalsoshowanincongruencebetweenexpressed
andassignedgender.Inaddition,theymustmeetatleasttwoofsix

criteria, half of which are related to their current (or in the cases of
early adolescents, future) secondary sex characteristics or desired
secondarysexcharacteristics.Othercriteriaincludeastrongdesireto
beanothergender,betreatedasanothergender,orthebeliefthatone
hasthetypicalfeelingsandreactionsofanothergender.
D. Epidemiology
1. Unknown,butrare.
2. Male-to-femaleratiois4:1.
3. Almostallgender-disorderedfemaleshaveahomosexualorientation.
4. Fifty percent of gender-disordered males have a homosexual
orientation, and 50% have a heterosexual, bisexual, or asexual
orientation.
5. The prevalence rate for transsexualism is 1 per 10,000 males and 1
per30,000females.
E. Etiology
Biologic. Testosterone affects brain neurons that contribute to
masculinizationofthebraininsuchareasasthehypothalamus.Whether
testosterone contributes to so-called masculine or feminine behavioral
patternsingenderidentitydisordersremainscontroversial.Sexsteroids
influencetheexpressionofsexualbehaviorinmaturemenandwomen
(i.e., testosterone can increase libido and aggressiveness in men and
women, while estrogen or progesterone can decrease libido and
aggressivenessinmen).
Table18-17
ClassificationofIntersexualDisordersa
Syndrome
Virilizingadrenal
hyperplasia
(andrenogenital
syndrome)

Turner’ssyndrome

Description
ResultsfromexcessandrogensinfetuswithXXgenotype;most
commonfemaleintersexdisorder;associatedwithenlargedclitoris,
fusedlabia,hirsutisminadolescence.

Resultsfromabsenceofsecondfemalesexchromosome(XO);
associatedwithwebneck,dwarfism,cubitusvalgus;nosex
hormonesproduced;infertile;usuallyassignedasfemalesbecause
offemale-lookinggenitals.
Klinefelter’ssyndrome GenotypeisXXY;malehabituspresentwithsmallpenisand
rudimentarytestesbecauseoflowandrogenproduction;weaklibido;
usuallyassignedasmale.
Androgeninsensitivity
CongenitalX-linkedrecessivedisorderthatresultsininabilityoftissues
syndrome(testiculartorespondtoandrogens;externalgenitalslookfemaleand
feminizingsyndrome)
cryptorchidtestespresent;assignedasfemales,eventhoughthey
haveXYgenotype;inextremeformpatienthasbreasts,normal


externalgenitals,shortblindvagina,andabsenceofpubicand
axillaryhair.
EnzymaticdefectsinXY Congenitalinterruptioninproductionoftestosteronethatproduces
genotype(e.g.,5-α
ambiguousgenitalsandfemalehabitus;usuallyassignedasfemale
reductasedeficiency,
becauseoffemale-lookinggenitalia.
17-hydroxysteroid

deficiency)
Hermaphroditism
Truehermaphroditeisrareandcharacterizedbybothtestesand
ovariesinsameperson(maybe46XXor46XY).
Pseudohermaphroditism Usuallytheresultofendocrineorenzymaticdefect(e.g.,adrenal
hyperplasia)inpersonswithnormalchromosomes;female
pseudohermaphroditeshavemasculine-lookinggenitalsbutareXX;
malepseudohermaphroditeshaverudimentarytestesandexternal
genitalsandareXY;assignedasmalesorfemales,dependingon
morphologyofgenitals.
aIntersexualdisordersincludeavarietyofsyndromesthatproducepersonswithgrossanatomic

orphysiologicaspectsoftheoppositesex.

Psychosocial. The absence of same-sex role models and explicit or
implicit encouragement from caregivers to behave like the other sex
contributes to gender identity disorder in childhood. Mothers may be
depressedorwithdrawn.Inborntemperamentaltraitssometimesresultin
sensitive, delicate boys and energetic, aggressive girls. Physical and
sexualabusemaypredispose.
F. Differentialdiagnosis
Transvesticfetishism. Cross-dressing for purpose of sexual excitement;
cancoexist(dualdiagnosis).
Intersexconditions.SeeTable18-17.
Schizophrenia.Rarely,truedelusionsofbeingothersex.
G. Courseandprognosis
Children.Coursevaries.Symptomsmaydiminishspontaneouslyorwith
treatment.Prognosisdependsonageofonsetandintensityofsymptoms.
Thedisorderbeginsinboysbeforetheageof4years,andpeerconflict
developsatabouttheageof7or8years.Tomboyismisgenerallybetter

tolerated. The age of onset is also early for girls, but most give up
masculinebehaviorbyadolescence.Fewer than10% ofchildren goon
totranssexualism.
Adults.Coursetendstobechronic.
Transsexualism—afterpuberty,distresswithone’sbiologicsexanda
desiretoeliminateone’sprimaryandsecondarysexcharacteristicsand
acquire those of the other sex. Most transsexuals have had gender
identity disorder in childhood; cross-dressing is common; associated


mentaldisorderiscommon,especiallyborderlinepersonalitydisorderor
depressivedisorder;suicideisarisk,butpersonsmaymutilatetheirsex
organstocoercesurgeonstoperformsexreassignmentsurgery.
H. Treatment
Children.Improveexistingrolemodelsor,intheirabsence,provideone
fromthefamilyorelsewhere(e.g.,bigbrotherorsister).Caregiversare
helped to encourage sex-appropriate behavior and attitudes. Any
associatedmentaldisorderisaddressed.
Adolescents. Difficult to treat because of the coexistence of normal
identitycrisesandgenderidentityconfusion.Actingoutiscommon,and
adolescents rarely have a strong motivation to alter their stereotypic
cross-genderroles.
Adults.
1. Psychotherapy.Setthegoalofhelpingpatientsbecomecomfortable
withthegenderidentitytheydesire;thegoalisnottocreateaperson
with a conventional sexual identity. Therapy also explores sexreassignment surgery and the indications and contraindications for
suchprocedures,whichseverelydistressedandanxiouspatientsoften
decidetoundergoimpulsively.
2. Sex-reassignmentsurgery.Definitiveandirreversible.Patientsmust
go through a 3- to 12-month trial of cross-dressing and receive

hormonetreatment. Seventypercentto 80%of patientsare satisfied
bytheresults.Dissatisfactioncorrelateswithseverityofpre-existing
psychopathology.Areported2%commitsuicide.
3. Hormonal treatments. Many patients are treated with hormones in
lieuofsurgery.
VIII. Paraphilias
Paraphiliasorperversionsaresexualstimulioractsthataredeviationsfrom
normalsexualbehaviors,butarenecessaryforsomepersonstoexperience
arousal and orgasm. Individuals with paraphilic interests can experience
sexual pleasure, but they are inhibited from responding to stimuli that are
normallyconsiderederotic.DSM-5listspedophilia,frotteurism,voyeurism,
exhibitionism, sexual sadism, sexual masochism, fetishism, and
transvestism with explicit diagnostic criteria because of their threat to
others and/or because they are relatively common paraphilias. They are
more common in men than in women. Cause is unknown. A biologic
predisposition (abnormal electroencephalogram, hormone levels) may be
reinforcedbypsychologicfactors,suchaschildhoodabuse.Psychoanalytic


theoryholdsthatparaphiliaresultsfromfixationatoneofthepsychosexual
phases of development or is an effort to ward off castration anxiety.
Learningtheoryholdsthatassociationoftheactwithsexualarousalduring
childhoodleadstoconditionedlearning.
Table18-18
Paraphilias
Disorder
Definition
Exhibitionism Exposinggenitalsinpublic;
rareinfemales.

GeneralConsiderations Treatment
Personwantstoshock
Insight-oriented
female—herreactionis
psychotherapy,
affirmationtopatient
aversiveconditioning.
thatpenisisintact.
Femaleshouldtryto
ignoreexhibitionistic
male,whoisoffensive
butnotdangerous,or
callpolice.
Fetishism
Sexualarousalwith
Almostalwaysinmen.
Insight-oriented
inanimateobjects(e.g.,
Behavioroftenfollowed
psychotherapy;
shoes,hair,clothing).
byguilt.
aversiveconditioning;
implosion,i.e.,patient
masturbateswith
fetishuntilitlosesits
arousaleffect
(masturbatory
satiation).
Frotteurism Rubbinggenitalsagainst

Occursincrowdedplaces, Insight-oriented
femaletoachievearousal
suchassubways
psychotherapy;
andorgasm.
usuallybypassive,
aversiveconditioning;
nonassertivemen.
grouptherapy;
antiandrogenic
medication.
Pedophilia
Sexualactivitywithchildren 95%heterosexual,5%
Placepatientin
underage13;most
homosexual.Highrisk
treatmentunit;group
commonparaphilia.
ofrepeatedbehavior.
therapy;insightFearofadultsexualityin oriented
patient;lowself-esteem.
psychotherapy;
10–20%ofchildren
antiandrogen
havebeenmolestedby
medicationto
age18.
diminishsexualurge.
Sexual
Sexualpleasurederived

Defenseagainstguilt
Insight-oriented
masochism frombeingabused
feelingsrelatedtosex—
psychotherapy;group
physicallyormentallyor
punishmentturned
therapy.
frombeinghumiliated
inwards.
(moralmasochism).
Sexual
Sexualarousalresulting
Mostlyseeninmen.
Insight-oriented
sadism
fromcausingmentalor
NamedafterMarquisde
psychotherapy;
physicalsufferingto
Sade.Canprogressto
aversiveconditioning.
anotherperson.
rapeinsomecases.