Abnormal Psychology: An Integrative Approach, 4th Edition, David H.

Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual and Gender Identity Disorders

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

OUTLINE
 1. Sexual Dysfunction Disorders
 Disorders of the Desire Phase
 - Hypoactive Sexual Desire Disorder
 - Sexual Aversion Disorder
 Disorders of the Arousal Stage
 - Female Sexual Arousal Disorder
 - Male Erectile Disorder Disorder
 - (Persistent Sexual Arousal Disorder)
 Disorders of the Orgasm Phase
 - Female Orgasmic Disorder
 - Male Orgasmic Disorder
 - Premature Ejaculation
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

OUTLINE (cont.)
 1. Sexual Pain Disorders
 Dyspareunia
 Vaginismus
2. Substance Induced Sexual Dysfunction

“Despite a lifetime of service to the cause of

sexual liberation I have never caught a
venereal disease, which makes me feel rather
like an arctic explorer who has never had
frostbite.”

Germaine Greer (1939 - )
Australian-born British writer and academic.

The Observer (London), "Sayings of the Week"

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Dysfunctions: An Overview

 Sexual Dysfunctions
 Affect desire, arousal, and/or orgasm
 Pain associated with sex can lead to additional dysfunction
 Males and Females
 Experience parallel versions of most sexual dysfunctions
 Affects about 43% of all females and 31% of males
 Most prevalent class of disorder in the United States
 Classification of Sexual Dysfunctions
 Lifelong vs. acquired
 Generalized vs. specific
 Psychological factors alone
 Psychological factors combined with medical conditions
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Figure 10.3 The human sexual response cycle.

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Desire Disorders

 1. Hypoactive Sexual Desire Disorder

 Low or no sexual desire:
- low or no sexual thoughts and fantasies
- low or no interest in initiating and participating in
sexual activities
- low or no awareness of sexual cues from others
 Accounts for half of all complaints at sexuality clinics
 Diagnosis made considering age and context
 Affects 20-35% of women and 15% of men
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Desire Disorders

 2. Sexual Aversion Disorder

 Active avoidance of sexual activities
 Physical / sexual contact – Extreme fear, panic,
disgust
 10% of males report panic attacks during sexual
activity
 Etiology
-Classically conditioned response
ASSAULT + SEX = FEAR, PANIC,
AVOIDANCE
UCS CS CR
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

 Hypoactive Sexual Desire Disorder and Sexual

Aversion Disorder
 Etiology
- Biological causes:
(hormonal) testosterone , prolactin , estrogen
(prescription and recreational drugs) antihypertensive,
antipsychotic, antidepressant, cocaine, alcohol, amps
(medical conditions) diabetes, cardiovascular diseases, MS,
Spinal chord injury, ANS injury, renal failure

- Socio-culturaland Psychological causes

Situational pressures, relationship problems,
contradictory cultural standards, psychological
factors, psychological disorders, sexual abuse
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Arousal Disorders

Problem is arousal, not desire

 4. Male Erectile Disorder

 Difficulty achieving and maintaining an erection
 Generally affects about 8-10% of males
 7% at age 40, 18% at 60, 27% at 70, 76% at 80
 Males are more troubled by the problem than
females
 Erectile problems are the main reason males seek
help
 10 of 63 cases of ED were caused
purely psychological factors, only 5
were the result of biological factors
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

 4. Male Erectile Disorder (cont)

 Etiology
 - Biological causes
 Hormonal abnormalities, vascular abnormalities
 Identifying organic causes: nocturnal penile tumescence

- Socio-cultural and Psychological causes

Job loss and financial stress, relationship problems
*2 Sexual Interaction Patterns
1. Inadequate sexual stimulation to aging husband
2. Only intercourse can give wife an orgasm
*Performance Anxiety and spectator role
Worry on sexual performance = self-evaluative
spectator: aroused participant
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Arousal Disorders

Problem is arousal, not desire

 5. Female Sexual Arousal Disorder

 Difficulty achieving and maintaining adequate
lubrication - swelling
 Affects about 10-50% of females
 Lack of sexual arousal is tied with orgasmic
dysfunctioning
 Subjective sexual arousal disorder
 - Absence of or markedly diminished feelings of
 sexual arousal, (sexual excitement and pleasure)
 Genital sexual arousal disorder
 - minimal vulval swelling or vaginal lubrication from
any type of sexual stimulation
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Arousal Disorders

Problem is arousal, not desire
 6. Persistent Sexual Arousal Disorder
 “sensations of insistent and persistent vaginal
congestion and other physical signs of sexual
 arousal in the absence of any initial or deliberate
 attempt to invoke desire or arousal”

 • Occasionally relieved by orgasm

 • Distressing, intrusive, and unwanted
 • A newly described syndrome (2001)
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Orgasm Disorders
 7. Inhibited Orgasm: Male Orgasmic Disorder
 Have adequate desire and arousal
 Unable to achieve orgasm
 Rare condition in adult males (1-3%)
 Similar to Psychogenic aspermia

 Etiology
 - low testosterone, neurological diseases, head injuries,
and drugs inhibiting arousal of sympathetic NS (fluoxetine)
 - performance anxiety and spectator role, hypoactive
sexual disorder
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Orgasm Disorders: An Overview

 8. Inhibited Orgasm: Female Orgasmic Disorder
 Have adequate desire and arousal
 Unable to achieve orgasm
 Most common complaint of adult females
 10-15% never had and/or rarely had an orgasm
 25% of adult females report difficulty reaching orgasm
 50% of adult females report experiencing regular orgasms
 Orgasm during intercourse per se is not critical to normal
sexual functioning
 “clitoral orgasm” and “vaginal orgasm”
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Orgasm Disorders: An Overview

 8. Inhibited Orgasm: Female Orgasmic Disorder
 Etiology
 - diabetes, MS, and postmenopausal changes in skin
sensitivity, (size and location of clitoris?)
 - Societal-cultural norms, sexually restrictive upbringing,
 - sexual abuse during childhood (50-70%)
 - unhappy childhood or loss of parent as a child
 - degree of emotional involvement and length of
relationship with partner
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Orgasm Disorders: An Overview

 9. Premature Ejaculation
 Ejaculation before the man or partner wishes it to
 Orgasm with minimal stimulation
 21% of all adult males meet diagnostic criteria
 Most prevalent sexual dysfunction in adult males
 Common in younger, inexperienced males
 Problem declines with age and experience

 Retrograde ejaculation is the least

common of the ejaculation problems.
It causes semen to back into the
bladder during orgasm instead
of exiting by way of the penis.
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Pain Disorders

 Defining Feature
 Marked pain during intercourse
 10. Dyspareunia
 From Latin words meaning “painful mating”
 Persistent or recurrent pain with attempted or
complete vaginal entry and/or penile vaginal
intercourse.
 Adequate sexual desire, arousal, and ability to attain
orgasm
 10% to 15% of women report pain during intercourse
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

VVS – inflammation of the vulvar vestibule (yellow arrows)

minimizing the vaginal opening causing pain on
intromission.
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Pain Disorders

 10. Dyspareunia
 Etiology
Injury during childbirth, scars of episiotomy, penis
hitting on remnants of hymen, wiry pubic hair, pelvic
diseases, and/ or allergic reactions to:
Vaginal douches
Contraceptives
Protein in male semen
Psychological causes are rare
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Pain Disorders: An Overview (cont.)

 11. Vaginismus
 Limited to females
 Persistent or recurrent difficulties to allow vaginal
entry of a penis, finger, and/or any object, despite
the woman’s expressed wish to do so. Often phobic
avoidance and anticipation of pain.
 Outer third of the vagina undergoes involuntary
spasms
 Complaints include feeling of ripping, burning, or
tearing
 Affects over 1-6% of women
 Prevalence rates are higher in more conservative
groups
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Pain Disorders: An Overview (cont.)

 PC Muscle group (dark 8 figure) contracts during

vaginismus
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Sexual Pain Disorders: An Overview (cont.)

 11. Vaginismus
 Etiology
Conditioned fear response, set off by anticipating
the vaginal penetration will be painful and
damaging
Fear is the result of anxiety and ignorance,
exaggerated stories of pain, trauma caused by an
earlier unskilled lover, and or trauma of childhood
sexual abuse
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Assessing Sexual Behavior and Sexual Dysfunction

 Comprehensive Interview
 History of sexual behavior, lifestyle, and associated
factors
 Medical Examination
 Must rule out medical causes of sexual dysfunction
 Psycho-physiological Evaluation
 Exposure to erotic material
 Determine extent and pattern of sexual arousal
 Males – Penile strain gauge
 Females – Vaginal photoplethysmograph
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Causes of Sexual Dysfunctions

 Biological Contributions
 Physical disease and medical illness
 Prescription medications
 Use and abuse of alcohol and other drugs
 Psychological Contributions
 The role of “anxiety” vs. “distraction”
 The nature and components of performance anxiety
 Psychological profiles associated with sexual dysfunction
 Social and Cultural Contributions
 Negative scripts about sexuality
 Learned negative attitudes about sexuality
 Negative or traumatic sexual experiences
 Poor interpersonal relationships, lack of communication
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Figure 10.6 A model of functional and dysfunctional sexual arousal.

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Psychosocial Treatment of Sexual Dysfunction

 Psychosexual Education alone

 Surprisingly effective
 Masters and Johnson’s Psychosocial Intervention
 Education
 Eliminate performance anxiety – Sensate focus
and non-demand pleasuring
 Additional Psychosocial Procedures
 Squeeze technique – Premature ejaculation
 Masturbatory training – Female orgasm disorder
 Use of dilators – Vaginismus
 Exposure to erotic material – Low sexual desire
problems
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Assessment
 1. Medical, psychosocial, and psycho-physiological
evaluations
 2. Clinical interviews and self-report questionnaires
(individual and couple)
 *3 sessions in length*
1st session: Introductory Remarks
Time for questions, Interview one partner
Other partner fills out questionnaires
2nd session: “Has anything changed?”
3rd session: Assess interaction between partners
(problems/strengths in communication)
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Assumptions

 Clients will:
- Be embarrassed
- Not understand medically correct
terminology
- Be misinformed about sexual
functioning
- Be in crisis
- Not have been open with one another about
sexual matters
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Goals

 1. Establish rapport (make them comfortable)

 2. Obtain a general description of sexual problems
 3. Obtain a thorough psychosocial history

 4. Obtain a description of other life concerns and current

stressors
 5. Determine whether sex therapy is appropriate for the
couple at this time
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Psychoeducation

 1. Anatomy (diagrams, models)

 2. Physiology
 3. Unrealistic expectations
 4. Myths about sexuality (hardest misconception to
dispel)

*Simple psycho-education may lead to rapid improvement

in the first few sessions
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

MYTHS OF MALE SEXUALITY

 1. Men should not have certain emotions
 2. In sex, it’s performance that counts.
 3. The man must take charge and orchestrate sex.
 4. A man always wants and is always ready to have sex.
 5. All physical contact must lead to sex.
 6. Sex equals intercourse.
 7. Sex requires and erection.
 8. Good sex is linear progression of excitement
terminated only by orgasm.
 9. Sex should be natural and spontaneous.
 10. In this enlightened age, myths 1-9 no longer have
any influence on us.
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

MYTHS OF FEMALE SEXUALITY

 1. Sex in only for women under 30.
 2. Normal women have an orgasm every time they have
sex.
 3. All women can have multiple orgasms.
 4. Pregnancy and delivery reduce women’s sexual
responsiveness.
 5. A woman’s sex life ends with menopause.
 6. There are different kinds of orgasm related to a
woman’s personality. Vaginal orgasms are more feminine
and mature than clitoral orgasms.
 7. a sexually responsive woman can always be turned
on by her partner.
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

MYTHS OF FEMALE SEXUALITY (cont)

 8. Nice women aren’t aroused by erotic books or films.
 9. you are frigid if you don’t like the more exotic forms of
sex.
 10. if you can’t have an orgasm quickly and easily,
there’s something wrong with you.
 11. Feminine women don’t initiate sex or become wild
and unrestrained during sex.
 12. You’re frigid if you don’t have sexual fantasies and a
wanton woman if you do.
 13. Contraception is a woman’s responsibility, and she’s
just making up excuses if she says contraceptive issues
are inhibiting her sexually.
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

Exploring Sexual Disorders

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 1. Hypoactive Sexual Desire and Sexual Aversion
 *Affectual awareness – visualizing sexual scenes to
uncover negative emotions about sex
 *Cognitive self-instruction training – learn to
generate “coping statements”
 *Desire diary – record sexual thoughts and feelings,
read and view erotic media, fantasize
 *Pleasurable shared activities – strengthen feelings
of sensual enjoyment and sexual attraction
 *In cases of molest, mock letters/ dialogues are
made to express feelings
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder
 • Sildenafil (Viagra)
 – 4 hour half-life: 1hr before planned sexual activity
 – Side effects: ~10% headache, flushing, dyspepsia,
nasal congestion, visual disturbances
 • Vardenafil (Levitra)
 – 1 hr before planned sexual activity: 4-6 hour half-
life
 • Tadalafil (Cialis)
 – 30 min before sexual activity: 17 hour half-life
 – Fewer side effects (no food absorption effect,
reduced
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder

EID Kit (free lubricant) for $80 only!

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Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder

Muscles relax allowing dilation and free blood flow

Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder
 *Yohimbine (bark of African yohimbe tree),
trazadone, apomorphine – involves
neurotransmitters

 *Penile prosthesis – surgical implantation of semirigid

rubber, wire, or silicon rods.
 *Topical creams
 *Inflatable prosthesis
 *Vascular surgery
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder
 *Yohimbine (bark of African yohimbe tree),
trazadone, apomorphine – involves
neurotransmitters
 *Penile prosthesis – surgical implantation of semirigid
rubber, wire, or silicon rods.
 *Topical creams – uncertain efficacy
 *Inflatable prosthesis
 *Vascular surgery – limited and short
 term benefit
*Tease technique added to Sensate Focus
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 2. Male Erectile Disorder:Non-demand Sensate Focus
Stage 1
– Touch body (no genitals or breast) with goal
of increasing awareness
– Limited touching: Ignore arousal
Stage 2
– Touching all over
– “receiver” guides hand of “toucher”
Stage 3
– Mutual touching that feels natural
– Begin to shift attention away from own body
onto partner’s : Intercourse is still off limits
Subsequent stages
– Increase genital touching with goal of arousal
– Proceed to intercourse when ready
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

 3. Male Orgasmic Disorder
 - Non-demand sensate focus by Masters and Johnson
 The focus is on enhancing and sustaining pleasure, not
orgasm and performance

4. Premature Ejaculation
*Stop-start or pause or just pull-out-and-stop technique
- stimulation of penis stops just before he ejaculates;
arousal subsides
- intromission but no thrusting
- female creates thrusting with slow and long strokes
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

4. Premature Ejaculation
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

5. Female Arousal and Orgasm Dysfunctions
*Self-exploration and body awareness
*Directed masturbation training
- step-by-step manner how to masturbate effectively
and, eventually, how to reach orgasm during sexual
interactions
- includes diagrams and reading materials, self-
stimulation, erotic material and fantasies, role playing,
sensate focus, and positional training.
- 90% trainees learned to have an orgasm
*Straightforward assurance of their normality
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

5. Vaginismus
 *Relaxation technique – education on how to relax
muscles at the opening of the vagina, gradually using
dilators
 *gradual behavioral
 exposure

 6. Dyspareunia
 * In physical causes, scars or lessions, appropriate
intercourse positions can be taught avoiding injured area
 *Gynecological exam must be made as majority of cases
are undiagnosed physical problems.
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

TREATMENT OF SEXUAL DYSFUNCTIONS

6. Dyspareunia
Abnormal Psychology: An Integrative Approach, 4th Edition, David H. Barlow
Chapter 10: Sexual and Gender Identity Disorders

SAMUEL H. AQUINO JR.