Download Advanced Psychopathology – PSY 306 Sexual Deviance and

Advanced Psychopathology – PSY 306
Sexual Deviance and
Sexual Dysfunction
Katie Seidler
Clinical and Forensic
Psychologist
Macquarie University, 2007
Sexual Deviance and Dysfunction
Introductions
Lecture Outline
What is normal sexual behaviour?
What constitutes deviance?
What is the difference between deviance
and dysfunction?
The distinction between fantasy and
behaviour.
Sexual Deviance and Dysfunction
Lecture outline continued…
Diagnostic definitions of deviance.
Defining features,
Prevalence,
Gender difference,
Comorbidity.
DSM-IV categories of sexual deviance.
Theories of deviance.
Clinical issues in dealing with sexual
material.
Definitions of sexual dysfunction.
Sexual Deviance and Dysfunction
Lecture outline continued…
DSM-IV categories of sexual
dysfunction.
Prevalence,
Comorbidity,
Clinical issues,
Psychosocial issues.
Sexual Deviance and Dysfunction
Small Group Discussion – what is
normal sexual behaviour?
Large group discussion – what is the
difference between deviance and
dysfunction?
Sexual Deviance and Dysfunction
Small Group Exercise - Scenarios
Sexual Deviance and Dysfunction
It is important to distinguish between
fantasy and behaviour.
Deviant fantasies are common.
Fantasy is not illegal but may be
concerning, depending on behaviour.
The continuum of sexual aggression.
Sexual Deviance and Dysfunction
Sexual Deviance – DSM-IV
Paraphilias are - characterised by
recurrent, intense sexual urges,
fantasies or behaviours that involve
unusual objects, activities or
situations and cause clinically
significant distress or impairment
in social, occupational or other
important areas of functioning.
Sexual Deviance and Dysfunction
Unusual objects usually involve:
non-human objects (i.e., shoes, hats
etc),
the suffering or humiliation of oneself
or one’s partner,
children or other non-consenting
persons.
Must have persisted for six months
or more.
May or may not be illegal.
Sexual Deviance and Dysfunction
Tends to develop in adolescence and be
refined with age and experience.
Tends to be chronic and lifelong, although
frequency and intensity may vary.
Reduces with age, as per “normal” sexual
trajectory.
Seems rare – but problems with
prevalence research.
Almost exclusively male – except maybe
sadomasochism.
Sexual Deviance and Dysfunction
Comorbidity:
Relationship problems – i.e., due to the shame,
disgust, embarrassment etc that one or both
parties in the relationship may experience.
Often associated with a reduced capacity for
intimacy and, therefore, other social and sexual
problems – including sexual dysfunction.
Many people present with multiple paraphilias.
Personality Disorders.
Other Axis I disorders – for example anxiety and
depression and these may be primary to or
secondary to the sexual deviance.
Sexual Deviance and Dysfunction
Associated issues:
Often illegal.
Most clients will be involuntary for
treatment and may be mandated by
Courts, external agencies, etc. This will
affect engagement and treatment outcome.
Often not associated with distress. Clients
often claim the “problem” lies in others’
responses. This is about justifying and
normalising their behaviour to alleviate guilt
and embarrassment.
Notions of deviance are socially
constructed.
Sexual Deviance and Dysfunction
Exhibitionism
Over a period of at least six months,
recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours
involving the exposure of one’s
genitals to an unsuspecting stranger.
This may or may not include
masturbation.
Sexual Deviance and Dysfunction
Fetishism
Over a period of at least six months, current,
intense sexually arousing fantasies, sexual urges,
or behaviours involving the use of nonliving
objects.
E.g., lingerie, shoes, etc.
NB: The fetish objects are not limited to articles of
female clothing used in cross-dressing or the
devices designed for the purpose of tactile genital
stimulation (e.g., a vibrator).
The fetishistic object is usually required or strongly
preferred for sexual excitement, such that in its
absence, men may experience erectile
dysfunction. Person may masturbate to the object
or ask partner to wear it.
Sexual Deviance and Dysfunction
Frotteurism
Over a period of at least six months,
recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours
involving touching and rubbing
against a non-consenting person.
Usually occurs in crowded place –
such as buses, trains etc.
Sexual Deviance and Dysfunction
Paedophilia
Over a period of at least six months, recurrent,
intense sexually arousing fantasies, sexual urges,
or behaviours involving sexual activity with a
prepubescent child or children.
NB: Child must be pre-pubescent – generally
under 12 (cf hebophilia).
NB: The person is at least age 16 years and at
least five years older than the child or children.
Specifiers:
Male children (more likely to recidivate)
Female children
Both
Intrafamilial/extrafamilial
Exclusive interest in children.
Sexual Deviance and Dysfunction
Sexual Masochism
Over a period of at least six months,
recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours
involving the act (real, not simulated) of
being humiliated, beaten, bound, or
otherwise made to suffer.
e.g.,
infantilism – being forced to act/dress like a
baby,
infibulation – piercing etc
bondage
hypoxyphilia.
Sexual Deviance and Dysfunction
Sexual Sadism
Over a period of at least six months,
recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours
involving acts (real, not simulated) in
which the psychological or physical
suffering (including humiliation) of the
victim is sexually exciting to the
person.
e.g., Jeffrey Dahmer.
Sexual Deviance and Dysfunction
Transvestic Fetishism
Over a period of at least six months, in a
heterosexual male, recurrent, intense
sexually arousing fantasies, sexual urges,
or behaviours involving cross-dressing.
Specify:
With Gender Dysphoria – i.e., discomfort with
their own gender.
Not if occurs in Gender Identity Disorder
May also include homosexual activity.
May also be engaged in as a form of
anxiety management or soothing.
Sexual Deviance and Dysfunction
Voyeurism
Over a period of at least six months,
recurrent, intense sexually arousing
fantasies, sexual urges, or behaviours
involving the act of observing an
unsuspecting person who is naked, in
the process of disrobing, or engaging
in sexual activity.
i.e., peeping tom stuff – usually
involves masturbation.
Sexual Deviance and Dysfunction
Paraphilia NOS
That is, anything else.
Can include:
Scatalogia (telephones),
Necrophilia,
Coprophilia,
Zoophilia etc…
Sexual Deviance and Dysfunction
Theories of Deviance
1. Inappropriate Arousal
The deviancy becomes reinforced by
the sexual pleasure associated with
masturbation or sexual behaviour,
with the main sustaining variable
relating to masturbation and fantasy,
which explains why the behaviour
does not extinguish in the absence of
behavioural reinforcement.
Sexual Deviance and Dysfunction
CONDITIONING THEORY OF
FETISHES
CS
STOCKINGS
US
SEX.INTERCOURSE
CR/UR
PLEASURE
Sexual Deviance and Dysfunction
CONDITIONING THEORY OF
FETISHES
CS
STOCKINGS
MASTURBATION
TO FANTASY
US
SEX.INTERCOURSE
CR/UR
PLEASURE
Sexual Deviance and Dysfunction
PERCENT ERECTION TO AUDIOS OF SEX VS
EXHIBITING
PERCENT FULL ERECTION
MARSHALL ET AL. (1991)
60
50
40
EXHIBITIONISTS
NON-OFFENDERS
30
20
10
0
SEX
EXHIBITING
SCENE
Sexual Deviance and Dysfunction
PENILE RESPONSE TO FILMS OF
ADULTS VS CHILDREN
(SETO ET AL., 1999)
CHILDREN
1.6 ADULTS
1.4
1.2
1
0.8
0.6
0.4
0.2
0
BIOL.
INCEST
LEGAL
INCEST
EXTERN. CONTROLS
INCEST
Sexual Deviance and Dysfunction
Problems with the theory:
Most people don’t recall the experiences of
pairing with the object and the arousal and
there may have only ever been one pairing,
which can’t explain the intensity or chronicity
of the deviance.
Most people present with multiple paraphilias
and this cannot be explained by the “pairing”
hypothesis.
Probably many males have accidental
pairings with deviant objects so why is the
incidence not higher?
Women experience sexual pleasure through
orgasm too so why do they not present with
paraphilias like men?
Sexual Deviance and Dysfunction
2. Poor Relationships
Research suggests that people with
sexual deviancy issues tend to be:
Less socially skilled,
Have greater intimacy deficits,
Have poor attachment skills,
Have fewer social skills with opposite
sex.
Sexual Deviance and Dysfunction
3. Lowered inhibition
Not developmentally delayed but may
be neurologically vulnerable – cause
or effect?
Most deviant people choose to lower
their inhibitions by justifying their
behaviour or engaging in distorted
thinking that supports the behaviour.
Sexual Deviance and Dysfunction
Examples:
I am not hurting anyone (Fetishism).
They don’t even know I’m there
(Voyeurism).
She will enjoy it (Frotteurism).
I am teaching him about sex
(Paedophilia).
It makes me feel better (Transvestic
Fetishism) etc.
Sexual Deviance and Dysfunction
Small Group Discussion – as
clinicians what do we need to be
mindful of in asking sexual questions?
Sexual Deviance and Dysfunction
Sexual Dysfunction - DSM-IV
Must cause distress and impairment.
Sexual Deviance and Dysfunction
Hypoactive Sexual Desire Disorder
Persistently and recurrently deficient (or absent)
sexual fantasies and desire for sexual activity.
Judgement of deficiency or absence is made by
the clinician and needs to take into account age,
life context etc.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Sexual Deviance and Dysfunction
Sexual Aversion Disorder
Persistent or recurrent extreme aversion to,
and avoidance of, all (or almost all) genital
sexual contact with a sexual partner.
The aversion may be manifest by anxiety,
fear, disgust, panic.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors
Sexual Deviance and Dysfunction
Female Sexual Arousal Disorder
Persistent or recurrent inability to attain, or
to maintain until completion of the sexual
activity, an adequate lubrication-swelling
response of sexual excitement.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Sexual Deviance and Dysfunction
Male Erectile Disorder
Persistent or recurrent inability to attain, or
to maintain until completion of the sexual
activity, an adequate erection.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Sexual Deviance and Dysfunction
Female Orgasmic Disorder
Persistent or recurrent delay in, or absence of,
orgasm following a normal excitement phase.
Women exhibit wide variability in the type or
intensity of stimulation necessary to bring about
orgasm and, therefore, the diagnosis should be
based on clinical judgement about the woman’s
general capacity for orgasm relative to her age,
sexual experience and sexual interest etc.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Sexual Deviance and Dysfunction
Male Orgasmic Disorder
Persistent or recurrent delay in, or absence of,
orgasm following a normal sexual excitement
phase during sexual activity that the clinician,
taking into account the person’s age, judges to be
adequate in focus, intensity and duration.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Sexual Deviance and Dysfunction
Premature Ejaculation
Persistent or recurrent ejaculation with minimal
sexual stimulation before, on, or shortly after
penetration and before the person wishes it. The
clinician should take into account factors that
affect the duration of the excitement phase, such
as age, novelty of the sexual partner or situation,
and recent frequency of sexual activity.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Sexual Deviance and Dysfunction
Dyspareunia
Recurrent or persistent genital pain associated
with sexual intercourse in either a male or a
female.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Most sufferers of Dyspareunia would seek
treatment in a general medical setting, rather than
a mental health clinic.
Sexual Deviance and Dysfunction
Vaginismus
Recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that
interferers with sexual intercourse.
Can’t be better accounted for by an Axis 1
condition, or due to the effects of a medical
condition or drug use.
Specifiers:
Acquired/Lifelong
Generalised/Situational
Due to psychological factors.
Often associated with younger women, women
who have negative attitudes about sex or who
have been the victim of sexual abuse.
Sexual Deviance and Dysfunction
Sexual Dysfunction Due to a General Medical
Condition
Clinically significant sexual dysfunction that results
in marked distress or interpersonal difficulty
predominates in the clinical picture.
There is evidence from the history, physical
examination, or laboratory findings that the sexual
dysfunction is fully explained by the direct
physiological effects of a general medical
condition.
Must not be better accounted for by an Axis 1
condition.
Can be specified as relating to the any of the
above Sexual Disorders, e.g., Male Erectile
Disorder due to Diabetes Mellitus. The medical
condition should also be coded on Axis III.
Sexual Deviance and Dysfunction
Substance Induced Sexual Dysfunction
Clinically significant sexual dysfunction that
results in marked distress or interpersonal
difficulty predominates the clinical picture.
There is evidence from the history, physical
examination, or laboratory findings, that the
sexual dysfunction is fully explained by
substance abuse and is manifested by
either:
Symptoms developed during, or within a
month of, Substance Intoxication,
Medication use of etiologically related to
the disturbance.
Sexual Deviance and Dysfunction
Cannot be accounted for by any other
diagnoses.
Substance should be specified – e.g.,
cocaine, amphetamines, opioid etc…
Specifiers:
With impaired desire,
With impaired arousal,
With impaired orgasm,
With sexual pain,
With onset during intoxication.
Sexual Deviance and Dysfunction
Sexual dysfunction NOS
That is, everything else.
Sexual Deviance and Dysfunction
Some additional points re: sexual
dysfunction:
1. There is an obvious overlap between
many of the diagnoses and therefore
clinical picture is unclear.
2. Prevalence – may be more common
than sexual deviance with rates between
5% to 43% depending on nature of
dysfunction.
3. More common in women than men – but
are there reasons for this?
Sexual Deviance and Dysfunction
4. Rates in women higher than for
deviance.
5. Sexual dysfunction increases with
age.
6. Years of education and marriage
negatively correlated with sexual
dysfunction.
7. Sexual dysfunction is commonly
associated with medical problems and
substances.
Sexual Deviance and Dysfunction
8. May be related to psychological
concerns.
9. Psychosocial factors related to sexual
dysfunction include:
Relationship problems,
Sociocultural standards about sex,
Religious views about sex,
Lack of education about sex,
Presence of significant stressors,
Traumas,
Extreme beliefs/standards,
Lack of communication.
Sexual Deviance and Dysfunction
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