Sexual & Paraphilic Disorder Exhibitionistic Disorder

Paraphilia  Male > Female

- intense & persistent sexual interest other than sexual Risk Factor
interest in genital stimulation (organ lain)  Temperamental: Exhibitionism, antisocial history,
- or preparatory fondling with phenotypically normal antisocial personality disorder, alcohol misuse,
(non-living thing) paedophilic sexual preference
- or physiologically mature (bawah umur)  Environmental: childhood sexual & emotional
- or consenting human partners (rape) abuse, sexual preoccupation/ hypersexuality
A ≥ 6 months, recurrent & intense sexual arousal
Paraphilic Disorder from exposure of one’s genitals to an
- paraphilia that is causing distress/ impairment to the unsuspecting person, as manifested by fantasy,
individual urges, or behaviour
- or a paraphilia whose satisfaction has entailed personal B Has acted on these urges with a nonconsenting
harm/ risk of harm to others person/ sexual urges or fantasy cause functional
impairment
Aetiology
Specify:
- Anxiety/ early emotional trauma
- Sexually aroused by exposing genitals to
- Standard pattern of arousal replaced by another
prepubertal child
pattern (early exposure to highly charged sexual
- Sexually aroused by exposing genitals to
experiences that replace the person’s experience of physically mature individual
sexual pleasure) - Sexually aroused by exposing genitals to
- Acquire symbolic and conditioning element (fetish) prepubertal children and to physically mature
individual
Types of Paraphilic Disorder Frotteuristic Disorder
Anomalous Activity Preference Anomalous  Male, seen at OPD
Courtship Algolagnic Target Risk Factor
Preference Temperamental: Frotteurism, non-sexual/ antisocial
Voyeuristic Sexual Paedophilic behaviour, sexual preoccupation/ hypersexuality
Exhibitionistic Masochism Fetishitic A ≥6 months, recurrent & intense sexual arousal
Frotteuristic Sexual Sadism Transvestic from touching/ rubbing against a nonconsenting
person, as manifested b fantasy, urge or
behaviour
Voyeuristic Disorder B Has acted on these urges with a nonconsenting
 Most common law-breaking behaviour person/ sexual urges or fantasy cause functional
Risk Factors impairment
 Temperamental: voyeurism Sexual Masochism Disorder
 Environmental: childhood sexual abuse, substance  Mean age onset ~19.3 y/o
misuse, sexual preoccupation/ hypersexuality  Risk of accidental death while practicing
A ≥ 6 months, recurrent and intense sexual arousal asphyxiophylia/ other autoerotic procedures
from observing an unsuspecting person who is A ≥ 6 months, recurrent & intense sexual arousal
naked, in the process of disrobing/ engaging in from the act of being humiliated, beaten, bound
sexual activity, as manifested by fantasies, urges or otherwise made to suffer, as manifested by
or behaviour fantasy, urges or behaviour
B Has acted on these sexual urges with a B Cause functional impairment
nonconsenting person/ the sexual urges or
fantasy cause clinically significant distress/ Specify:
impairment functioning - with asphyxiophilia: practice of achieving sexual
C Experiencing the arousal and/or acting on the arousal related to restriction of breathing
urges is ≥ 18 y/o Sexual Sadism Disorder

Specify
- in a controlled environment
- in full remission: no distress/ functional
impairment ≥ 5 yrs with in uncontrolled
environment
(applied to all paraphilic disorder except
paedophilic)
A ≥6 months, recurrent & intense sexual arousal
from the physical/ psychological suffering of
another person, as manifested by fantasy, urges
or behaviour
B Has acted on these urges with a nonconsenting
person/ sexual urges or fantasy cause functional
impairment
Paedophilic Disorder
 Aware of strong preference sexual interest in Specify
children around the time of puberty – the same - with fetishism: fabric, material, garments
time frame in which males who later prefer - with autogynephilia : sexually aroused by
physically mature partners (become aware on their thought/ image of self as female
sexual interest in men/ women)
Risk Factors Treatment
 Temperamental: paedophilia, anti-social 1. Psychotropic medication if a/w comorbid psychiatric
personality disorder illness
 Environmental: sexual abuse by children 2. Antiandrogen, long acting GnRH, SSRI, naltrexone to
 Genetic & physiological: neurodevelopmental reduce sex drive and fantasy
perturbation in utero increases the probability of 3. CBT
development of a paedophilic orientation 4. Social skill training
A ≥6 months, recurrent intense sexually arousing 5. Group therapy
fantasy, sexual urges, or behaviour involving 6. Insight-oriented therapy
sexual activity with a prepubescent child/
7. 12 steps program
children (generally ≤ 13 y/o)
I. Acceptance
B Has acted on these sexual urges, or the sexual
II. Hope
urges cause marked distress/ interpersonal
difficulty III. Willingness
C ≤ 16 y/o and ≥ 5 years older than the child/ IV. Personal inventory
children in criteria A (not include those in late V. Self-disclosure
adolescence involved in an ongoing sexual VI. Reflection
relationship, age 12-13 y/o) – kalau kurang 16 VII. Humility
thn, sexual curiosity VIII. Amends list
IX. Made amends
Specify X. Continued inventory
- Exclusive type (attracted only to child) XI. Spiritual growth
- Nonexclusive XII. Giving back
- Sexually attracted to male
- Sexually attracted to female
Types of Sexual Disorder
- Sexually attracted to both
1. Sexual Desire Disorder 5. Sexual Dysfunction d/t
- Limited to incest (closed relative)
GMC
Fetishistic Disorder
2. Sexual Arousal 6. Substance Induced
 Associated with sexual dysfunction during
Disorder Sexual Dysfunction
romantic reciprocal relationships when the
3. Orgasm Disorder 7. Sexual Dysfunction not
preferred fetish object/ body part in unavailable
4. Sexual Pain Disorder otherwise specified
during foreplay/ coitus
 Some individual may prefer solitary sexual activity
a/w fetishistic prefetence Sexual Desire Disorder
A ≥6 months, recurrent and intense sexual arousal Male Hypoactive Sexual Desire Disorder
from either the use of non-living objects/ a
 Lack of desire for sexual activity over a prolonged
highly specific focus on nongenital body part as
period resulting in a failure to initiate/ respond to
manifested by fantasy, urges or behaviour
sexual intimacy
B Functional impairment
Associated Features
C The fetish objects are not limited to articles of - Erectile/ ejaculatory concerns
clothing used in cross-dressing (as in transvestic - No longer initiate sexual activity and that they are
disorder) / devices specifically designed for the minimally receptive to a partner’s attempt to initiate
purpose to tactile genital stimulation (vibrator) Risk Factors
Temperamental: Mood & anxiety symptoms
Specify Environmental: Alcohol Use
- Body parts Genetic & Physiological: Endocrine disorder
- Nonliving objects (hyperprolactinemia, low testosterone), Age
- Others
A Persistently/ recurrent deficient (or absent)
Transvestic Disorder sexual/ erotic thoughts or fantasy and desire for
 With arrival of puberty, dressing in women’s sexual activity. The judgement is made by the
clothes begins to elicit penile erection and in some clinician, taking into account factors that affect
cases leads directly to first ejaculation sexual functioning (age, general, sociocultural)
A ≥6 months, recurrent & intense sexual arousal B ≥ 6 months
from cross-dressing, as manifested by fantasy, C Significant distress in the individual
urges or behaviour D Not better explain by a nonsexual mental
B Functional impairment disorder/ consequence of severe relationship
 distress/ other stressors/ substance/ Environmental: relationship difficulty, partner sexual
medication/ medical condition functioning, developmental history (early relationship
with caregivers and childhood stressors)
Specify Genetic & physiological: medical condition (DM,
- Lifelong: present since the individual become thyroid), genetic on vulnerability to sexual problems)
sexually active Associated with:
- Acquired: began after a period of relatively - problems in experience orgasm
normal sexual function - pain during sexual activity
- Generalized: not limited to certain type of - infrequent sexual activity
stimulation, situation or partners - couple-level discrepancies in desire
- Situational: Only in certain types of stimulation, - relationship difficulties
situation or partners - mood disorders
- Mild: mild distress over criteria A Treatment
- Moderate: moderate distress over criteria A - Sex education
- Severe: severe/ extreme distress of criteria A - Cognitive Tx
Sexual Arousal Disorder - Create non-demanding situations
Male Erectile Dysfunction - work on relationship problems
Fail erection during intercourse - use artificial lubricants
Associated Features - Vacuum pump for clitoris
- Low self esteem & self confidence A Lack/ significant reduced sexual interest/
- ↓ sense of masculinity arousal, ≥ 3 of following
- Depressed affect 1. Reduced interest in sexual activity
- Fear / avoidance of future sexual encounter 2. Reduced sexual/ erotic thoughts/ fantasy
- ↓ sexual satisfaction and reduced sexual desire in 3. Reduced initiation of sexual activity, typically
the individual partners unreceptive to a partner attempts to initiate
Risk Factors 4. Reduced sexual excitement/ pleasure during
Temperamental: sexual activity in almost all sexual encounters
- Neurotic Personality Traits 5. Reduced sexual interest/ arousal in response
- Submissive Personality Traits to any internal/ external sexual/ erotic cues
- Alexithymia 6. Reduced genital/ non-genital sensations
- Depression / PTSD during sexual activity in almost all sexual
Treatment encounters
Non Pharmacology: vacuum device B ≥ 6 months
Pharmacology: C Significant distress
Sildenafil, Vardenafil, Tadalafil D Not better explained
A ≥ 3, on almost all/ all occasions of sexual activity Orgasm Disorder
1) Difficulty in obtaining an erection during Premature Ejaculation
sexual activity Sense of lack of control over ejaculation
2) Difficulty in maintaining an erection until the Associated Features
completion of sexual activity - sense of lack of control over ejaculation
3) Decrease in erectile rigidity - report apprehension (anxiety) about their
B ≥ 6 months anticipated inability to delay ejaculation on future
C Significant distress sexual encounters
D Not better explained … Aetiology
Specify: Temperamental: Men with anxiety disorder (social
- Lifelong/ Acquired phobia)
- Generalized/ Situational Genetic & Physiological: dopamine transporter gene
- Mild/ Moderate/ Severe polymorphism/ serotonin transporter gene
polymorphism , thyroid disease, prostatitis, drug
withdrawal
Female Sexual Arousal Disorder A Persistent/ recurrent pattern of ejaculation
- Most common: ↓ sexual desire occurring during partnered sexual activity within
Causes approximately 1 minute following vaginal
- Life stress penetration and before the individual wishes it
- Aging, menopause (for nonvaginal sexual activity, no specific time)
- Inadequate sexual stimulation B ≥ 6 months, on almost of all occasions of sexual
- General health, medical regimen activity
- Relationship problems C Significant distress
Aetiology: D Not better explained
Temperamental: -ve cognition & attitudes about
sexuality, H/o mental disorder, difference in Specify
propensity for sexual excitation and sexual inhibition - lifelong/ acquired
 - generalized/ situational Anxiety
- mild/ moderate/ severe with/ withot
Vaginismus
sexual
Delayed Ejaculation response
Difficulty in reaching orgasm during coitus with
partner
Associated Features
Fear of pain
- report of prolonged thrusting to achieve orgasm to with Dyspareunia
intercourse
the point of exhaustion/ genital discomfort & then
ceasing the efforts
- some men avoiding sexual activity because of a Vaginismus - Persistent/ recurrent genital pain
repetitive pattern of difficulty ejaculating occurring before, during or after intercourse
- sexual partners feeling less attractive because their Anxiety with sexual response – Involuntary
partner cannot ejaculate easily persistent constriction of outer 1/3rd of vagina that
prevent penile insertion
Aetiology
Age related loss of the fast-conducting peripheral Aetiology
sensory nerves & age-related decreased sex steroid - H/o sexual trauma (rape, abusive partner,
secretion may be a/w the ↑ in delayed ejaculation in childhood history)
men ≥ 50 y/o - Anticipation of pain at the 1st coital experiences
A Either of the following, on almost all occasions of - Strict religious upbringing that associate sex w/ sin
partnered sexual activity, without the individual - Problems in dyadic (b/w 2) relationship; woman
desiring delay who feels emotionally abused by her partner may
1. Marked delay in ejaculation protest in this nonverbal fashion
2. Marked infrequency/ absence of ejaculation - Experienced pain in childhood d/t surgery/ dental
intervention become guarded about any breach of
B ≥ 6 months
body integrity
C Significant distress
D Not better explained…. Associated Features
- ↓ sexual desire
- Behavioural avoidance of sexual situations
Specify
- Avoid gynaecology examination
- lifelong/ acquired
- Come to Tx only when wish to conceive
- generalized/ situational
- Associated with relationship problem
- mild/ moderate/ severe
- Symptoms diminish feeling of femininity
Female Organismic Disorder
A Persistent/ recurrent difficulties with ≥ 1 of
Recurrent/ persistent inhibition of female orgasm
following
Associated Features
1. Vaginal penetration during intercourse
- problems with sexual interest and arousal
2. Vulvovaginal/ pelvic pain during vaginal
Aetiology
intercourse/ penetration attempts
Temperamental: Anxiety & concern about pregnancy
3. Fear/ anxiety about vulvovaginal or pelvic
Environment: relationship problems, physical health,
pain in anticipation of, during, or as a result
mental health, orgasm difficulty in women
of vaginal penetration
Genetic & physiological: medical condition (multiple
4. Tensing/ tightening of the pelvic floor
sclerosis, pelvic nerve damage from radical
muscles during attempted vaginal
hysterectomy, spinal cord injury, vulvovaginal
penetration
atrophy), SSRI drugs
B ≥ 6 months
A Either of the following, on almost all occasions of
C Clinical significant distress
sexual activity
1. Marked delay in, marked infrequency of, or D Not better explained by….
absence of orgasm Specify:
2. Marked reduced intensity of orgasmic - Lifelong/ acquired
sensation - Mild/ Moderate/ Severe
B ≥ 6 months
C Significant distress Drug Induced Sexual Dysfunction
D Not better explained… 1. Antipsychotic
2. Antidepressants
Specify 3. Sympathomimetic – amphetamines,
- lifelong/ acquired methyphenidate, pemoline
- generalized/ situational 4. Α and β blocker
- mild/ moderate/ severe 5. Anticholinergic - amantadine, benztropine
- never experience an orgasm under any 6. Alcohol
situation 7. Opioids – heroin
8. Cannabis – prolonged use
Sexual Pain Disorder
Genito-Pelvic Pain/ Penetration Disorder
Non Pharmacological Treatment
1. Dual Sex Therapy
2. Specific Technique & Exercise (pinch at corona
ridges of glans)
3. Hypnotherapy
4. Behaviour Therapy
5. Group Therapy
6. Analytically Oriented Sex Therapy
7. Biological Therapy
 Pharmacotherapy – Sildenafil
 Vacuum Pump
 Male Prosthesis