Sexual Health and Reproductive Education - Health - 11th Grade by Slidesgo

Sexual and gender
identity disorders
Classification of sexual disorderand gender
identity disorder
DSM-5 ICD-10
SEXUAL DYSFUNCTIONS SEXUAL DYSFUNCTION NOT CAUSED BY ORGANIC DISORDERS
Sexual desire/arousal disorder Lack or loss of sexual desire
Female sexual/arousal disorder Sexual aversion and lack of sexual enjoyment
Male hypoactive sexual desire disorder Failure of genital response
Erectile disorder
identity disorder
DSM-5 ICD-10
ORGASM DISORDERS ORGASMIC DYSFUNCTIONS
Female orgasmic disorder Premature ejaculation
Delayed ejaculation Non-organic dyspareunia
Premature ejaculation Non organic vaginisismus
Genitopelvic pain/penetration
disorder(specific phobia)
Excessive sexual drive
Substance /medication-induced sexual
dysfunction
identity disorder
DSM-5 ICD-10
PARAPHILIC DISORDER DISORDER OF SEXUAL PREFERENCE
Exhibitionist disorder Exhibitionism
Frotteuristic disorder Voyeurism
Sexual masochism disorder Sadomasochism
Sexual sadism disorder

identity disorder
DSM-5 ICD-10
PARAPHILIC DISORDER DISORDER OF SEXUAL PREFERENCE
Anomalous target preferences Paedophilia
Paedophilic disorder Fetishism
Fetishistic disorder Fetishistic transvestism
Transvestic disorder
identity disorder
DSM-5 ICD-10
GENDER DYSPHORIA GENDER IDENTITY DISORDERS
IN CHILDREN
IN ADULTS
SEXUAL DYSFUNCTION
1. Sexual dysfunction is a problem that can happen during any phase
of the sexual response cycle. It prevents you from experiencing
satisfaction from sexual activity.
2. The sexual response cycle traditionally includes excitement,
plateau, orgasm and resolution. Desire and arousal are both part of
the excitement phase of the sexual response. It’s important to know
women don’t always go through these phases in order.
3. While research suggests that sexual dysfunction is common, many
people don’t like talking about it. Because treatment options are
available, though, you should share your concerns with your partner
and healthcare provider.
TYPES OF SEXUAL dysfunction
Sexual dysfunction generally is classified into four categories:
Desire disorders: lack of sexual desire or interest in sex.
Arousal disorders: inability to become physically aroused or excited during sexual activity.
Orgasm disorders: delay or absence of orgasm (climax).
Pain disorders: pain during intercourse.
Who is affected by sexual dysfunction?
Sexual dysfunction can affect any age, although it is more common in those over 40 because it’s often
related to a decline in health associated with aging.
TYPES OF SEXUAL dysfunction
Sexual dysfunction generally is classified into four categories:
Desire disorders: lack of sexual desire or interest in sex.
Arousal disorders: inability to become physically aroused or excited during sexual activity.
Orgasm disorders: delay or absence of orgasm (climax).
Pain disorders: pain during intercourse.
Who is affected by sexual dysfunction?
Sexual dysfunction can affect any age, although it is more common in those over 40 because it’s often
related to a decline in health associated with aging.
Symptoms and Causes
In people assigned male at birth:
Inability to achieve or maintain an erection (hard penis) suitable for intercourse (erectile dysfunction).
Absent or delayed ejaculation despite enough sexual stimulation (retarded ejaculation).
Inability to control the timing of ejaculation (early, or premature, ejaculation).
In people assigned female at birth:
Inability to achieve orgasm.
Inadequate vaginal lubrication before and during intercourse.
Inability to relax the vaginal muscles enough to allow intercourse.
In everyone:
Lack of interest in or desire for sex.
Inability to become aroused.
Pain with intercourse.
Causes
Physical causes::
Diabetes, heart and vascular (blood vessel)
Neurological disorders,
Hormonal imbalances
Chronic diseases such as kidney or liver failure
Alcohol use disorder and substance use disorder.
Antidepressant drugs
Antidepressants
Tricyclic antidepressants, including amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil), and nortriptyline
(Aventyl, Pamelor)
Monoamine oxidase inhibitors (MAOIs), including phenelzine (Nardil) and tranylcypromine (Parnate)
Antipsychotic medications, including thioridazine (Mellaril), thiothixene (Navane), and haloperidol (Haldol)
Anti-mania medications such as lithium carbonate (Eskalith, Lithobid)
Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
Causes
Anti-hypertensive medications (used to treat high blood pressure)
Diuretics, including spironolactone (Aldactone) and the thiazides (Diuril, Naturetin, and others)
Centrally acting agents, including methyldopa (Aldomet) and reserpine (Serpasil, Raudixin)
a-Adrenergic blockers, including prazosin (Minipress) and terazosin (Hytrin)
b-adrenergic (beta) blockers, including propranolol (Inderal) and metoprolol (Lopressor)
The following medications may decrease sexual desire:
Hormones
Leuprolide (Lupron)
Goserelin (Zoladex)
What medications can cause sexual dysfunction?
Some prescription medications and even over-the-counter drugs can have an impact on sexual functioning. Some
medicines can affect libido (desire) and others can affect the ability to become aroused or achieve orgasm. The risk
of sexual side effects is increased when an individual is taking several medications.
Diagnosis and test
.
In most cases, you recognize something’s interfering with your enjoyment (or a partner's enjoyment) of a sexual
relationship. Your provider usually begins with a complete history of symptoms and a physical. They may order
diagnostic tests to rule out medical problems that may be contributing to the dysfunction. Typically lab testing plays
a very limited role in the diagnosis of sexual dysfunction.
An evaluation of attitudes about sex, as well as other possible contributing factors —fear, anxiety, past sexual
trauma/abuse, relationship concerns, medications, alcohol or drug abuse, etc. — helps a clinician understand the
underlying cause of the problem and recommend the right treatment.
Can sexual dysfunction be cured?
The success of treatment for sexual dysfunction depends on the underlying cause of the problem. The outlook is good for
dysfunction that is related to a condition that can be treated or reversed.
Management and treatment
.
Medication: When a medication is the cause of the dysfunction, a change in the medication may help. Men and women with hormone
deficiencies may benefit from hormone shots, pills or creams. For men, drugs, including sildenafil (Viagra®), tadalafil (Cialis®),
vardenafil (Levitra®, Staxyn®) and avanafil (Stendra®) may help improve sexual function by increasing blood flow to the penis. For
women, hormonal options such as estrogen and testosterone can be used (although these medications are not approved for this purpose).
In premenopausal women, there are two medications that are approved by the FDA to treat low desire, including flibanserin (Addyi®)
and bremelanotide (Vyleesi®).
Mechanical aids: Aids such as vacuum devices and penile implants may help men with erectile dysfunction (the inability to achieve or
maintain an erection). A vacuum device (EROS-CTD™) is also approved for use in women, but can be expensive. Dilators may help
women who experience narrowing of the vagina. Devices like vibrators can be helpful to help improve sexual enjoyment and climax.
Sex therapy: Sex therapists can people experiencing sexual problems that can’t be addressed by their primary clinician. Therapists are often
good marital counselors, as well. For the couple who wants to begin enjoying their sexual relationship, it’s well worth the time and effort
to work with a trained professional.
Behavioral treatments: These involve various techniques, including insights into harmful behaviors in the relationship, or techniques such as
self-stimulation for treatment of problems with arousal and/or orgasm.
Psychotherapy: Therapy with a trained counselor can help you address sexual trauma from the past, feelings of anxiety, fear, guilt and poor
body image. All of these factors may affect sexual function.
Education and communication: Education about sex and sexual behaviors and responses may help you overcome anxieties about sexual
function. Open dialogue with your partner about your needs and concerns also helps overcome many barriers to a healthy sex
Sexual desire/arousal disorder
Sexual interest/arousal disorder is characterized by absence of or a decrease in sexual interest, initiation of sexual
activity, pleasure, thoughts, and fantasies; absence of responsive desire; and/or lack of subjective arousal or of
physical genital response to sexual stimulation—nongenital, genital, or both.
Sexual interest/arousal disorder in women is lack of or decreased interest in sexual activity (low libido) and sexual
thoughts and/or lack of response to sexual stimulation.
Temporary changes in sexual desire or arousal are common throughout a woman's sexual life. However, sexual
interest/arousal disorder causes interest in sexual activity and response to sexual stimulation to be persistently
decreased or absent. Lack of sexual interest and inability to be sexually aroused are considered a disorder only if
they distress the woman and if interest is absent throughout the sexual experience.
Usually, a woman feels sexually excited, mentally and emotionally, when sexually stimulated. There may also be certain
physical changes. For example, the vagina releases secretions that provide lubrication (causing wetness). Blood flow
to the genitals increases, causing the tissues around the vaginal opening (labia) and the clitoris (which corresponds to
the penis in men) to swell, the breasts swell slightly, and these areas may tingle. In sexual interest/arousal disorder,
all or some of these responses are absent or significantly decreased.
Sexual desire/arousal disorder
Sexual interest/arousal disorder is classified as follows:
Subjective: A woman does not feel aroused by any type of sexual stimulation, including, kissing, dancing, watching an
erotic video, and physical stimulation of the genital area. However, a woman with subjective sexual interest/arousal
disorder may have a physical response to sexual stimulation. For example, blood flow to the clitoris increases
(causing it to swell), and the increased blood flow causes vaginal secretions to increase.
Genital: A woman feels aroused in response to stimulation that does not involve the genitals (such as an erotic video),
but does not respond to physical stimulation of the genitals. Vaginal secretions and/or sensitivity of the genitals is
reduced.
Combined: A woman feels little or no arousal in response to any type of sexual stimulation. The physical response
(increased blood flow to the genitals and production of vaginal secretions) is minimal or absent. She may report that
she needs external lubricants and that the clitoris no longer swells.
Causes
The cause of sexual interest/arousal disorder is often not known. Known causes are
Psychological factors, such as a lack of communication between partners and other relationship problems, depression, anxiety, negative sexual
self-image stress, and distractions
Unsatisfying sexual experiences
Physical factors, such as certain chronic disorders, menopause, genitourinary syndrome of menopause, certain medications, fatigue, and
debility
Certain chronic disorders (such as diabetes or multiple sclerosis) can damage nerves, reducing blood flow to and/or sensation in the genital
area.
Use of certain medications, including antidepressants (particularly selective serotonin reuptake inhibitors), opioids, some antiseizure
medications, and beta-blockers, can reduce sexual desire, as can drinking excessive amounts of alcohol.
Many women experience a decrease in sexual interest after menopause due to the natural aging process or surgical removal of the ovaries
(oophorectomy). Estrogen and progesterone levels decrease significantly after menopause. Testosterone decreases gradually with age but
does not change suddenly at menopause.
However, overall, sexual interest/arousal disorder is as common among young healthy women as it is among older women. Still, changes in
sex hormones sometimes cause lack of interest. For example, in young healthy women, sudden drops in levels of sex hormones, as may
occur during the first few weeks after childbirth, may cause sexual interest to decrease. In middle-aged and older women, sexual desire
may decrease, but a connection between the decrease and hormones has not been proven.
The decrease in estrogen that occurs at menopause can cause genitourinary syndrome of menopause (which causes symptoms affecting the
vagina, vulva, and urinary tract). In this syndrome, the tissues of the vagina can become thin, dry, and have difficulty stretching. As a
Diagnosis
A doctor's evaluation based on specific criteria
Doctors base the diagnosis of sexual interest/arousal disorder on the woman’s history and description of the problem and
on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the
American Psychiatric Association. These criteria require a lack of or decrease in at least three of the following:
Interest in sexual activity
Initiation of sexual activity and responsiveness to a partner's initiation
Excitement or pleasure during almost all sexual activity
Sexual or erotic fantasies or thoughts
Physical sensations in the genital area or elsewhere during sexual activity
Interest or arousal in response to sexual stimuli—written, spoken, or visual
These symptoms must have been present for at least 6 months and must cause significant distress in the woman.
A pelvic examination is done if penetration during sexual activity causes pain.
Treatment
Treatment of the cause, if possible
General measures
Psychological therapies
Medications
Care for women with sexual interest/arousal disorder is best managed by a team of several types of health care
professionals (a multidisciplinary team). The multidisciplinary team may include primary care doctors or
gynecologists, sex counselors, pain specialists, psychotherapists, and physical therapists.
One of the most helpful measures for sexual interest/arousal disorder is for women to identify and tell their partner which
things stimulate them. Women may need to remind their partner that they need preparatory activities—which may
involve touching or not—to get ready for sexual activity. For example, they may want to talk intimately, watch a
romantic or erotic video, or dance. Women may want to kiss, hug, or cuddle. They may want more or different
foreplay (their partner touching various parts of their body, then the breasts or genitals) before moving to sexual
intercourse or other sexual activity that involves penetration. Couples may experiment with different techniques or
activities (including fantasy and sex toys) to find effective stimuli.
Measures recommended to treat sexual dysfunction in general can also help increase interest in sex. For example,
eliminating distractions (such as a television in the bedroom) and taking measures to improve privacy and a sense of
Treatment
Psychological therapies, particularly mindfulness-based cognitive therapy, may benefit some women. Mindfulness
involves focusing on what is happening in the moment. Mindfulness-based cognitive therapy, usually done in small
groups, combines mindfulness and cognitive-behavioral therapy. It can help with arousal, orgasm, and the desire for
sexual activity.
Doctors may refer women with sexual interest/arousal disorder to a sex counselor or therapist or a psychotherapist.
Other treatments depend on the cause. For example, if medications may be contributing, they are stopped if possible.
Treatment of contributing factors
If women have sexual pain, effective treatment of the pain may resolve issues with lack of sexual interest or arousal. This
may be due togenitourinary syndrome of menopause, vulvodynia (chronic pain around the vulva), levator ani
syndrome, pelvic infections, fibroids, endometriosis, or other causes.
Testosterone therapy
Little is known about the long-term effectiveness and safety of testosterone (taken by mouth or as a skin cream). When
taken for a short time, a testosterone used at the same time as estrogen (and usually a progestogen) can be effective
in postmenopausal women with sexual interest/arousal disorder. However, use of testosterone for this purpose is
considered experimental and women should discuss risks and benefits with their doctor.
There are no prescription testosterone medications manufactured for women in the United States. However, some doctors
Treatment
Other therapies
Flibanserin can be used to treat premenopausal women with female sexual interest/arousal disorder. However, there is
little evidence for its effectiveness and safety.
Bremelanotide is used for treatment of low libido in women. It is an injection administered at least 45 minutes before
anticipated sexual activity.
Devices such as vibrators or clitoral suction stimulators may help, but there is little evidence to support their
effectiveness. Some of these products are available over the counter and may be tried.
Male hypoactive sexual desire disorder
Hypoactive sexual desire disorder is a psychiatric disorder that occurs in approximately 1.5% of men aged 16-44. The
prevalence of low sexual desire, more broadly, is approximately 15%-17% of men. Older men are more likely than
men in younger cohorts to experience low desire. Hypoactive sexual desire disorder is characterized by a low desire
for sex and absent sexual thoughts or fantasies.
Male hypoactive sexual desire disorder is sometimes associated with erectile and/or ejaculatory problems. Men with
this disorder may also have difficulty obtaining an erection, which can lead to a reduced interest in sex. Men with
hypoactive sexual desire disorder often report that they no longer initiate sexual activity and that they are minimally
receptive to a partner's attempt to initiate. Sexual activities, like masturbation, may occur even in the presence of low
sexual desire. Although men are more likely to initiate sexual activity, and thus low desire may be characterized by a
pattern of non-initiation, many men may prefer to have their partner initiate sexual activity. In such situations, the
man's lack of response to a partner's invitation should be considered when evaluating this disorder.
Male hypoactive sexual desire disorder
. There are five factors that should be taken into consideration during the assessment
and diagnosis of male hypoactive sexual desire disorder:
Partner’s sexual history and health status
Relationship quality such as ability to effectively communication, differences in sexual activity preference)
Individual factors such as body image, history of physical or sexual abuse, psychiatric comorbidity, life stressors
Cultural and religious background such as rules and attitudes towards sexual activity and sexuality
Medical background and treatment
Not all incidents of low sexual desire in men warrants a diagnosis of Male Hypoactive Sexual Desire Disorder.
Therefore, not all treatments for low sexual desire are psychiatric. If a diagnosis is warranted, there are treatment
options available. However, there are few controlled studies evaluating the efficacy of treatment options. Treatment
recommendations are published in Psychiatry and Journal of Sex and Marital Therapy.
Erectile disorder
Erectile dysfunction (ED) is a type of penile disorder. It
affects your ability to get and maintain an erection firm
enough for sexual intercourse.
Your feelings play a major role in getting and maintaining an
erection. Feeling relaxed, confident and aroused is
essential. But it’s normal to sometimes have erection
issues. Erection problems can occur if you feel nervous,
anxious, frustrated or tired. Drinking alcohol and/or
using substances can also have an effect. It can also result
from other conditions or as a side effect of certain
medications or cancer treatments.
Types of Erectile dysfunction
1. Healthcare providers separate ED into several categories:
2. Vascular erectile dysfunction. Vascular ED includes causes that affect the blood vessels that send blood to the
tissues in your penis that allow you to get and maintain an erection, or the valves in the penis that normally hold
blood inside. Vascular ED is the most common type of ED.
3. Neurogenic erectile dysfunction. Neurogenic ED occurs as a result of nerve problems, which prevent signals from
traveling from your brain to your penis to create an erection. This can happen because of trauma, pelvic surgery,
radiation therapy or neurologic conditions like stroke, spinal stenosis and multiple sclerosis (MS).
4. Hormonal erectile dysfunction. Hormonal ED refers to ED that happens as a result of testosterone deficiency, or in
some cases as a result of thyroid issues.
5. Psychogenic erectile dysfunction. Psychogenic ED involves psychological conditions (conditions that affect your
thoughts, feelings or behavior) that can cause ED.
6. How common is erectile dysfunction?
7. Erectile dysfunction is the most common sex-related condition that men and people assigned male at birth ( AMAB)
report to healthcare providers, especially as they age and develop other health issues
Symptoms and causes
Erectile dysfunction symptoms include:
Only sometimes being able to get an erection before sexual intercourse.
Being able to get an erection before sexual intercourse but not being able to maintain it during sexual intercourse.
Complete inability to get an erection.
Requiring a lot of stimulation to maintain an erection.
What causes erectile dysfunction?
There are many possible causes of ED, including conditions that affect your:
Circulatory system. Your circulatory system includes the blood vessels that carry blood throughout your body. Your
penis needs adequate blood flow to become erect and maintain an erection. Your penis also relies on a series of
valves to close when it fills with blood — in some cases, these valves stop working as they should.
Nervous system. Your nervous system includes your brain, spinal cord and nerves. They work together to send electrical
impulses that help your body move and feel, including your penis.
Endocrine system. Your endocrine system includes the glands that create and release hormones. Hormones help tell your
body to perform certain functions. Testosterone may help open up (vasodilate) your blood vessels, which helps blood
flow to your penis.
Symptoms and causes
The factors may include:
Certain conditions or diseases
Diabetes and diabetes-related neuropathy.
High blood pressure (hypertension).
High cholesterol (hyperlipidemia).
Vascular disease.
Chronic kidney disease.
Atherosclerosis.
Peyronie’s disease.
Low testosterone (testosterone deficiency).
Stroke.
Epilepsy.
Injuries (trauma) to your penis and surrounding areas can also cause ED. They include:
Penile fracture.
Injuries to your pelvis bones (hip bones, sacrum and tailbone), bladder, prostate and spinal cord.
Pelvic surgery, including prostate, colon or bladder cancer surgery.
Radiation therapy.
Symptoms and causes
Certain medications
Erectile dysfunction is a common side effect of many prescription drugs. Common medications that list ED as a potential
side effect include:
Antidepressants.
Anti-anxiety medications (anxiolytics).
Blood pressure medications.
Diuretics.
Antihistamines.
Chemotherapy drugs.
Parkinson’s disease drugs.
Prostate cancer drugs.
Antiarrhythmics.
Sedatives.
Muscle relaxers.
Antiseizure medications.
Symptoms and causes
Other substances
Substances that have addiction potential may cause ED, including:
Alcohol.
Amphetamines.
Barbiturates.
Cocaine.
Marijuana.
Methadone.
Nicotine.
Opioids.
Psychological and/or emotional conditions
Depression.
Anxiety.
Stress.
Fear of sexual intercourse or intimacy (genophobia).
Low self-esteem.
What is the primary cause of erectile dysfunction?
Conditions that affect your body’s ability to deliver blood to your penis are the most common cause of ED.
Erectile dysfunction
Who does erectile dysfunction affect?
You may have a greater risk of getting ED if you:
Are 40 or older.
Have diabetes.
Have a body mass index (BMI) over 25.
Have depression.
Are physically inactive.
Smoke.
Diagnosis and Tests
These questions may make you feel embarrassed or awkward. But it’s important to be honest with the provider in order
to quickly determine the cause. The questions may include:
Are you currently taking any medications, including prescription drugs, over-the-counter drugs, herbal supplements,
dietary supplements and nonmedical drugs?
• Has a healthcare provider ever diagnosed you with depression or anxiety?
• Do you often feel stressed?
• Are you experiencing any relationship problems?
• How often are you able to get erections?
Erectile dysfunction
How hard are your erections?
How long are you able to maintain an erection?
Do you lose your erection because you ejaculate sooner than you would like?
When did you first notice symptoms of erectile dysfunction?
What exactly happened when you first had erectile dysfunction symptoms?
Do or did you experience erections at night or during the morning?
What sexual positions do you regularly engage in?
The provider may also ask to talk with your sexual partner. Your partner may be able to offer additional insight on
potential causes.
What tests will be done to diagnose erectile dysfunction?
It depends on what your healthcare provider suspects is causing erectile dysfunction. Your provider may order:
Blood tests.
Complete blood count (CBC).
Lipid panel.
Liver function tests.
Kidney function tests.
Thyroid tests.
Testosterone test.
The first step in treating erectile dysfunction is identifying the underlying cause. A healthcare provider will help
determine the best treatment for you. Treatment options may include:
Cardiovascular exercise. Vigorous cardiovascular exercise for at least 45 minutes three times per week may help
reverse some cases of mild ED. Cardiovascular exercises may include brisk walking, jogging, swimming, bicycling
and jumping rope.
Quitting smoking. For men with mild ED, quitting smoking can lead to improvement after several months.
Talking to a sex therapist.
Oral medications that help increase blood flow to your penis, including sildenafil (Viagra®), vardenafil (Levitra®),
tadalafil (Cialis®) or avanafil (Stendra®). Oral medications start to work within an hour.
Penile low-intensity focused shockwave therapy (LiSWT). This noninvasive treatment improves blood flow by using
sound waves. It can take two months to see improvement.
Medications you inject directly into your penis to create an erection, including alprostadil (Caverject®), papaverine
(Papacon®), phentolamine (Regitine®) or a combination of multiple medications. Injectable medications start to
work within 10 minutes.
Vacuum constriction device (penis pump). Penis pumps start to work almost immediately.
Testosterone replacement therapy, which is available as a gel, injection, patches and pellets. Testosterone replacement
therapy starts to work within four weeks.
Penile implant procedure. A penile implant is a procedure in which a surgeon places a device into your penis to make it
hard. The device doesn’t affect sensation, peeing or orgasm.
Will ED go away on its own?
ED will not likely go away on its own without changes to your lifestyle or some kind of treatment.
• Prevention
Reducing your cholesterol.
Being more physically active, especially doing cardiovascular exercises like running, jogging or bicycling.
Maintaining a healthy weight for you.
Getting high-quality sleep.
Eating healthy foods with low saturated fats, such as fruits, vegetables and whole grains.
Stopping smoking.
Reducing or stopping drinking.
Outlook / Prognosis
• The outlook for ED is good and it’s a very treatable condition. Though there aren’t cures for some causes of ED,
many treatment options can help you get and maintain an erection hard enough for sexual intercourse.
Female Orgasmic disorder
female orgasmic disorder involves orgasm that is absent, infrequent, markedly diminished in intensity, or
markedly delayed in response to stimulation despite normal levels of subjective arousal.
Female orgasmic disorder can be primary or secondary:
Primary: Women have never been able to have an orgasm.
Secondary: Women were previously able to have an orgasm but are now no longer able to do so.
What makes the problem rise to the level of FOD? There are specific criteria for diagnosing the disorder in
women:
A woman will rarely—or never—be able to reach orgasm, even when she is sexually aroused
These symptoms last for six months or more
The problem causes significant distress and problems in her relationships
Orgasm difficulties are not exclusively caused by another medical condition or medication
The problem affects a sizable number of women. In the largest US study of female sexual dysfunction, including
responses from over 30,000 women, the prevalence of FOD was approximately 21%.
What causes FOD?
There are many physical and psychological factors that may be involved in FOD.
As mentioned above, there are medical conditions that can make it more difficult for a woman to achieve orgasm. In
particular, conditions that affect the nervous system such as multiple sclerosis or spinal cord injuries that affect the
nerves of the pelvis can make reaching orgasm more difficult. Arthritis, thyroid problems, and asthma have also been
associated with FAD. But research has found that is often isn’t the medical condition alone—it’s also the stress of
managing a chronic illness and pain the effect of this on a woman’s emotional wellbeing.
Certain medications can affect a woman’s ability to reach orgasm. Antidepressants (serotonin reuptake inhibitors, or
SSRIs, in particular) antipsychotics, antihistamines and drugs high blood pressure are some of the medications who
may inhibit orgasm in women.
There are a number of psychological factors that may affect a woman’s ability to orgasm. Fatigue, stress, anxiety, and
depression all can contribute to the problem. Poor body image can also cause anxiety and discomfort and affect a
woman’ ability to reach orgasm.
Relationship issues are another common cause. Problems in the relationship, including anger and mistrust,
communications problems, or other sexual problems can interfere with sexual pleasure and orgasm.
A woman’s cultural or religious beliefs may be factor. For example, a woman may have been raised with the belief that
a woman shouldn’t seek out or enjoy sex, and may feel embarrassed or guilty about enjoying sex.
Women with orgasmic disorder may have other types of sexual dysfunction (eg, dyspareunia, pelvic floor dysfunction)..
Anxiety disorders and depression are also more common among women with this disorder.
Factors that contribute to female orgasmic disorder include
Contextual factors (eg, consistently insufficient foreplay, early ejaculation by the partner, poor communication about
sexual preferences)
Psychological factors (eg, anxiety, stress, lack of trust in a partner)
Cultural factors (eg, lack of recognition of or attention paid to female sexual pleasure)
Medications (eg. some antipsychotics or, commonly, selective serotonin reuptake inhibitors [SSRIs])
Lack of knowledge about sexual function
Damage to genital sensory or autonomic nerves or pathways (eg, due to diabetes or multiple sclerosis)
Vulval dystrophy (eg, lichen sclerosus)
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria (1)
Clinicians interview the woman and, sometimes, her partner; the woman is asked to describe the problem in her own
words and should include specific elements (see table Components of the Sexual History for Assessment of Female
Sexual Dysfunction ).
Diagnosis of orgasmic disorder is clinical, based on criteria in the DSM-5-TR:
Delayed, infrequent, or absent orgasm or markedly decreased intensity of orgasm after a normal sexual arousal phase on
all or almost all occasions of sexual activity
Distress or interpersonal problems due to orgasmic dysfunction
No other disorder or substance that exclusively accounts for the orgasmic dysfunction
Symptoms must have been present for ≥ 6 months.
Because the type of stimulation that triggers orgasm varies widely, clinicians must use clinical judgment to determine
whether the woman's response is deficient, based on her age, sexual experience, and adequacy of the sexual
stimulation she receives.
Treatment of Female Orgasmic disorder
Self-stimulation
Sex therapy
Data support encouraging self-stimulation (masturbation). First-line treatment of female orgasmic disorders is directed
masturbation, which involves a series of prescribed exercises.
A vibrator placed on the mons pubis close to the clitoris may help, as may increasing the number and intensity of
stimuli), simultaneously if necessary. Education about sexual function (eg, need to stimulate other areas of the body
before the clitoris) may help.
Sex therapy for women, with or without their partners, can often help them with concerns about sexual performance and
feelings.
Other psychological therapies, including cognitive-behavioral therapy and psychotherapy, may help women identify and
manage fear of vulnerability and issues of trust with a partner. Recommending the practice of mindfulness and using
mindfulness-based cognitive therapy (MBCT) can help women pay attention to sexual sensations (by staying in the
moment) and not judge or monitor these sensations.
Currently, no data suggest that any medication is efficacious in the treatment of female orgasmic disorder.
Delayed ejaculation
Delayed ejaculation, also called delayed orgasm, happens when you take a long time and need a lot of stimulation to
reach sexual climax and ejaculate (the term for when semen is forcefully pushed out of your penis). In some cases,
you might not ejaculate at all.
Delayed ejaculation, also called delayed orgasm, was previously called male orgasmic disorder. The inability to ejaculate
is called anejaculation. Being unable to reach a climax (orgasm) is called anorgasmia.
There’s really no “normal” time limit for how long it should take to orgasm. However, if you have delayed ejaculation,
the time it does take may cause stress for you and possibly for your partner.
Who does delayed ejaculation affect?
Factors that can make delayed ejaculation more likely include:
Having diabetes, mostly type 1 diabetes, multiple sclerosis, a stroke or spinal cord injury.
Getting older.
Having had surgery on your bladder or prostate.
Taking certain medications, including some drugs that treat depression, psychosis, high blood pressure and pain.
Mental health or relationship issues.
Delayed ejaculation
How common is delayed ejaculation?
There are estimates that 1% to 4% of men in the U.S. have delayed ejaculation.
Symptoms and Causes

Usually, men are able to ejaculate after only minutes of sexual stimulation. One symptom of delayed ejaculation is that it
takes you 30 minutes or more to climax.
Another issue is that you might get physically tired. You might actually even start to feel some pain. Both of these things
might also be true for your partner, if there’s a partner involved. Your partner could feel hurt thinking they aren’t
attractive enough or skillful enough to stimulate you to orgasm.
What’s important, really, is how you feel. If you’re frustrated or upset by the time that it takes you to ejaculate, or if you
don’t ejaculate, then it’s a problem that needs to be addressed.
What causes delayed ejaculation?
Physical causes may include:
Nervous system conditions, such as stroke, spinal cord injury and multiple sclerosis. Nerve damage can also happen as a
complication of diabetes and surgery.
Hypothyroidism.
Some type of blockage in your penis.
Using certain prescription medications, like antidepressants, or using street drugs.
Delayed ejaculation
Psychological or emotional causes may include:
Feeling guilty about sex, possibly due to your upbringing.
Feeling angry at or uncomfortable with your partner.
Being afraid of something, such as disease, pregnancy or hurting your partner.
Having sexual performance anxiety.
Being addicted to pornography.
Diagnosis and Tests
Your healthcare provider will ask you questions about your medical history, sexual habits and ejaculation patterns. They
will rule out other conditions, possibly doing laboratory testing on hormones (testosterone), urine (pee) or semen.
Finally, your feelings about how and when you ejaculate are an important part of the diagnosis. Your healthcare provider
may also want to ask your partner some questions.
Treatment of Delayed ejaculation
Your healthcare provider may offer you a number of different kinds of treatments. There really isn’t one clear way to
treat the condition, though, except if it’s caused by certain drugs or alcohol use. You can stop using the drugs and cut
down on the drinking.
If delayed ejaculation is a side effect of prescription drugs, you can work with your healthcare provider to switch to
another medicine that may not have the same effect on you.
Your healthcare provider might refer you to other medical professionals like a sex therapist and/or a more traditional type
of counselor. If delayed ejaculation happens primarily with your partner, your healthcare provider might suggest
counseling for both you and your partner.
If you see a sex therapist, they might suggest using erotic materials or devices to help you ejaculate both by yourself and
with a partner.
Treatment of Delayed ejaculation
. Medications
There isn’t an approved drug treatment for delayed ejaculation, and that includes supplements. However, some healthcare
providers prescribe medicines on an “off-label” basis with a small degree of success. Some of these medicines are:
Testosterone, a hormone.
Cyproheptadine (Periactin®), an antihistamine.
Buspirone (BuSpar®), a treatment for anxiety.
Amantadine (Symmetrel®), a treatment for Parkinson’s disease.
Oxytocin (Pitocin®), a hormone used in childbirth to strengthen uterine muscle to contract and produced by the body
during orgasm.
Cabergoline, a drug that promotes dopamine levels.
What is the prognosis (outlook) for delayed ejaculation?
The outlook for delayed ejaculation caused by a substance that you can quit taking is good, but the outlook for delayed
ejaculation caused by other things is not as good.
Premature ejaculation
. Premature ejaculation occurs in men when semen leave the body (ejaculate) sooner than wanted during sex. Premature
ejaculation is a common sexual complaint. As many as 1 out of 3 people say they have it at some time.
Premature ejaculation isn't cause for concern if it doesn't happen often. But you might be diagnosed with premature
ejaculation if you:
Always or nearly always ejaculate within 1 to 3 minutes of penetration
Are not able to delay ejaculation during sex all or nearly all the time
Feel distressed and frustrated, and tend to avoid sexual intimacy as a result
Premature ejaculation is a treatable condition. Medications, counseling and techniques that delay ejaculation can help
improve sex for you and your partner.
Premature ejaculation
Symptoms
The main symptom of premature ejaculation is not being able to delay ejaculation for more than three minutes after
penetration. But it might occur in all sexual situations, even during masturbation.
Premature ejaculation can be classified as:
Lifelong. Lifelong premature ejaculation occurs all or nearly all the time beginning with the first sexual encounter.
Acquired. Acquired premature ejaculation develops after having previous sexual experiences without problems with
ejaculation.
Many people feel that they have symptoms of premature ejaculation, but the symptoms don't meet the criteria for a
diagnosis. It's typical to experience early ejaculation at times.
How common is premature ejaculation?
Between 30% and 40% of men experience premature ejaculation at some point in their life. According to the American
Urological Association, premature ejaculation is the most common type of sexual dysfunction in men. About one in
five men between the ages of 18 and 59 report incidences of premature ejaculation.
Diagnosis and test
If you have frequent premature ejaculations, or if premature ejaculation is causing you anxiety or depression and
affecting your relationship, make an appointment to see a urologist.
Your urologist will begin an exam by asking about your sexual experiences. You will likely be asked:
How long have you had this problem?
Under what circumstances does it happened?
How often does it happen?
Does premature ejaculation happen at every sexual attempt?
Does it happen with all partners?
Does premature ejaculation occur when you masturbate?
Do you have trouble maintaining an erection?
While the questions are personal, it is important that you answer your urologist honestly so they can best diagnose the
source of your problem.
Your urologist will also ask about any other medical conditions you may have and any medications including over-the-
counter medications, supplements and herbal products you are taking. You will also be asked about any alcohol and
illegal drug use.
Treatment
There are many different treatments options for premature ejaculation depending on the cause
Behavioral therapy involves trying different methods to delay your orgasm. Its goal is to teach you how to control your
body and your feelings. Methods include:
Start and stop: With this technique, you or your partner stimulates your penis close to the point of orgasm then stops the
stimulation for about 30 seconds until you regain control of your response. Repeat this “start and stop” approach
three or four times before allowing yourself to orgasm. Continue practicing this method until you have gained good
control.
Squeeze therapy: With this technique, you or your partner stimulates your penis close to the point of orgasm then gently
squeezes the head of your penis for about 30 seconds so that you begin to lose your erection. Repeat this technique a
few times before allowing yourself to orgasm. Continue practicing this technique until you have gained control in
delaying your orgasm.
Distracted thinking: With this technique, the idea is to focus your attention on ordinary nonsexual things while you’re
being sexually stimulated. Naming sequences are a good way to focus your attention. For example, visualize naming
all the businesses you pass on your drive to the gym, naming all the players on your favorite sports team or naming
all the products on the aisles of your favorite store.
Treatment
Counseling
If the cause of your premature ejaculation is psychological, emotional, or due to relationship issues – due to performance
anxiety, depression, stress, guilt, or a troubled relationship – seek the help of a psychologist, psychiatrist, couples
therapist or sex therapist. Your urologist can help direct you to these health professionals.
Medications
Several types of medications may be tried.
Antidepressants, especially selective serotonin reuptake inhibitors like citalopram (Celexa®), escitalopram (Lexapro®),
fluoxetine (Prozac®), paroxetine (Paxil®) and sertraline (Zoloft®) or the tricyclic antidepressant clomipramine
(Anafranil®), can help delay premature ejaculation. This is an “off-label” use (not approved by the Food and Drug
Administration for this use). Be sure to discuss the side effects of this medication with your urologist to be sure it’s
appropriate for you.
Anesthetic (numbing) creams and sprays applied to the head and shaft of the penis is another medication option to delay
ejaculation. The anesthetic cream or spray is applied to the penis, absorbed for 10 to 30 minutes or until you feel less
sensitivity in your penis. It’s important to wash your penis before sex to prevent numbness to your partner’s vagina
or loss of your erection.
Erectile dysfunction medications, which include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®) and
Genito-pelvic pain/penetration
disorder
Genito-pelvic pain/penetration disorder involves difficulties with attempted or completed vaginal penetration
during sexual intercourse, including involuntary contraction of the pelvic floor muscles when vaginal entry is
attempted or completed (levator ani syndrome, or vaginismus), pain (dyspareunia) that is localized to the
vestibule (provoked vestibulodynia) or at other vulvovaginal or pelvic locations, and fear or anxiety about
penetration attempts.
Aetiology
(Women with genito-pelvic pain/penetration disorder commonly have impaired arousal, orgasm, or both.
Etiology of Genito-Pelvic Pain/Penetration Disorder
Causes of genito-pelvic pain/penetration disorder may involve physical and psychological factors.
Superficial vulvar pain may result from provoked vestibulodynia, genitourinary syndrome of menopause, dermatologic
disorders (eg, lichen sclerosus, vulvar dystrophies), congenital malformations, genital herpes simplex, vaginitis,
Bartholin gland abscess, radiation fibrosis, postsurgical introital narrowing, or recurrent tearing of the posterior
fourchette.
Provoked vestibulodynia can be primary or secondary:
Primary: Is present from the first experience with penetration (whether by insertion of a tampon, a speculum
examination, or sexual intercourse)
Secondary: Develops in patients who have previously been able to have comfortable, pain-free penetration
The etiology of provoked vestibulodynia is not entirely understood and may result from multiple factors, possibly
including an inflammatory or immune response, an increased number of nerve fibers resulting in hyperesthesia, a
hormonal imbalance, and pelvic floor dysfunction. Provoked vestibulodynia can occur in chronic pain syndromes,
including fibromyalgia, interstitial cystitis, and irritable bowel syndrome.
Deep dyspareunia may result from pelvic floor muscle hypertonicity or uterine or ovarian disorders (eg, fibroids,
chronic pelvic inflammatory disease, endometriosis).
A history of trauma or sexual trauma can also contribute to a genito-pelvic pain/penetration disorder.
Symptoms and signs
Women with primary provoked vestibulodynia report that pain occurred during their first experience with penetration.
Many notice the pain first in adolescence, when they first try to use a tampon. They may report that they have never
been able to have had comfortable sexual intercourse. Often, pain is described as a burning or stabbing pain caused
by insertion of something into the vagina. Women with secondary provoked vestibulodynia have similar symptoms,
but they report symptoms after a period of sexual activity without pain.
Women with genito-pelvic pain/penetration disorder may develop a phobia-like avoidance of penetration. They may have
an intense fear of and anxiety about pain before or during vaginal penetration. When women anticipate that pain will
recur during penetration, their vaginal muscles tighten, making attempts at sexual intercourse even more painful.
However, most women with this disorder can enjoy nonpenetrative sexual activity.
The inability to have sexual intercourse can strain a relationship. Women may feel ashamed, embarrassed, inadequate, or
depressed. It causes significant stress for women who want to become pregnant.
Diagnosis
.
Diagnosis of genito-pelvic pain/penetration disorder is based on specific criteria in the DSM-5-TR. The criteria require
persistence or recurrence of one or more of the following:
1. Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
2. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or because of vaginal
penetration
3. Marked tensing or tightening of pelvic floor muscles during attempted vaginal penetration
4. Symptoms must have been present for ≥ 6 months and must cause significant distress in the woman. Also, the
diagnosis of genito-pelvic pain/penetration disorder requires that sexual dysfunction is not better explained by the
presence of another disorder, severe relationship distress (eg, intimate violence), or other significant stressors or by
use a substance or medication.
Treatment
Treatment of cause when possible (eg, topical estrogen for genitourinary syndrome of menopause)
Education about chronic pain and its effects on sexuality
Pelvic floor physical therapy
Progressive desensitization
Management of genito-pelvic pain/penetration disorder frequently includes the following:
Encouraging and teaching the couple to develop satisfying forms of nonpenetrative sex
Discussing psychological issues contributing to and caused by the chronic pain
When possible, treating the primarily physical abnormality that contributes to pain (eg, endometriosis, lichen sclerosus,
vulvar dystrophies, vaginal infections, congenital malformations, radiation fibrosis)
Treating coexisting pelvic muscle hypertonicity
Treating comorbid sexual interest/arousal disorder
Topical estrogen is helpful for genitourinary syndrome of menopause, atrophic vaginitis, and recurrent posterior
fourchette tearing. Topical estrogen, intravaginal prasterone (a preparation of dehydroepiandrosterone, or DHEA),
or ospemifene (a selective estrogen receptor modulator [SERM]) may be useful in women with dyspareunia due to
vulvar dystrophies, or genitourinary syndrome of menopause.
Treatment
Data about the optimal treatment of genito-pelvic pain/penetration disorder are limited, and many approaches are
currently used depending on the specific presentation.
The first approach is always a reminder to practice good vulvar hygiene, including wearing cotton underwear during the
day, washing with a mild soap, and avoiding douching and over-the-counter vaginal deodorants. If a lubricant is used
during sex, it should be nonscented and water-based.
Pelvic floor physical therapy can often benefit women with genito-pelvic pain/penetration disorder; it includes pelvic
floor muscle training, sometimes with biofeedback, to teach pelvic muscle relaxation. Other therapies include soft-
tissue mobilization and myofascial release, trigger-point pressure, electrical stimulation, bladder and bowel
retraining, and therapeutic ultrasonography.
Prescription and nonprescription devices are available for self-dilation if women with genito-pelvic pain/penetration
disorder have tight pelvic muscles that contribute to painful intercourse. Self-dilation in the presence of a therapist
and the woman's partner plus psychotherapy has been shown to enable women with levator ani syndrome to have
sexual intercourse more frequently (1).
Treatment
Levator ani syndrome (previously called vaginismus) can be treated with progressive desensitization; women
progressively accustom themselves to self-touch near, on, then through the introitus. Each stage in the progression
begins only when the woman is comfortable with the previous stage.
The woman touches herself daily as close to the introitus as possible, separating the labia with her fingers. (Once her fear
and anxiety due to introital self-touch has diminished, the woman will be more able to tolerate the physical
examination.)
The woman inserts her finger past her hymen; pushing or bearing down during insertion enlarges the opening and eases
entry.
The woman inserts vaginal cones in gradually increasing sizes progressively; leaving a cone inside for 10 to 15 minutes
helps perivaginal muscles become accustomed to gently increasing pressure without reflex contraction.
The woman then allows her partner to help her insert a cone during a sexual encounter to confirm that it can go in
comfortably when she is sexually excited.
The couple includes penile vulvar stimulation during sexual play so that the woman becomes accustomed to feeling the
penis on her vulva.
Ultimately, the woman inserts her partner’s penis partially or fully, holding it like an insert. She may feel more confident
in the woman superior position.
For provoked vestibulodynia, first-line treatment includes pelvic floor physical therapy because pelvic floor muscle
Treatment
A topical hormone cream can often help when used for several months. For example, in one study of women who were
taking estrogen-progestin contraceptives (a potential cause of vulvar pain) and who had pain of the vulvar vestibule
(vestibulodynia), treatment with topical combined estradiol and testosterone therapy was effective (2).
Topical estrogen is helpful for genitourinary syndrome of menopause and to prevent tissue fragility, which may
result in recurrent posterior fourchette lacerations.
A topical lidocaine gel can also be applied before activities that cause discomfort during sexual intercourse; this gel
should be used only for a short time.
Topical estrogen, intravaginal prasterone (a DHEA preparation), or ospemifene (a selective estrogen receptor modulator
[SERM]) may be useful in women with dyspareunia due to genitourinary syndrome of menopause.
Medications used to treat neuropathic pain (eg, gabapentin, pregabalin) can be useful for provoked vestibulodynia. These
medications can lessen pain when they are used with other treatments for provoked vestibulodynia.
Tricyclic antidepressants, often used to treat chronic pain disorders, are a 2nd-line treatment for provoked
vestibulodynia. Amitriptyline and nortriptyline are the tricyclic antidepressants most commonly used and should be
started at a low dose and titrated up.
Various topical compounds containing combinations of gabapentin and amitriptyline may also be effective and, when
applied directly to the vaginal vestibule, have fewer systemic adverse effects.
Botulinum toxin type A, injected into the pelvic floor muscles, has been used to treat levator ani syndrome and provoked
Treatment
1. Referral to a certified sex therapist for psychological therapies such as cognitive-behavioral therapy, and
mindfulness-based cognitive therapy can often help women manage their fear of and anxiety about pain and
penetration.
Substance abuse sexual dysfunction
1. Substance-induced sexual dysfunction refers to a condition in both men and women in which patients have
difficulties with sexual desire, arousal, and/or orgasm due to a side effect of certain medications (legal or illicit).
This diagnosis is made based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),
criteria of a clinically significant sexual dysfunction that causes significant distress to the individual and the
symptoms of which develop during or soon after substance intoxication or withdrawal or after exposure to a
medication.
Incidence of this condition is likely underreported due to a variety of factors, including patient shame /
embarrassment as well as acceptance that these side effects are an unavoidable part of treatment. It has been cited
that as many as 50% of patients taking antipsychotic medications will have adverse sexual side effects, and
somewhere between 25% and 80% of patients taking antidepressants may as well.
1. Men may complain of erectile dysfunction, premature or absent ejaculation, anorgasmia, and/or pain with
intercourse. Women may complain of decreased lubrication / dryness, decreased engorgement, anorgasmia, pain
with intercourse, and/or decreased libido.
Common risk factors associated with sexual dysfunction include the individual’s general health state, the presence of
non-communicable diseases such as diabetes mellitus, cardiovascular diseases, genitourinary diseases,
psychiatric/psychological disorders, and chronic diseases. 4 The association between substance use and sexual
dysfunction has been increasingly recognised. 5
Substance use disorders are a global problem and contribute to preventable mortality and morbidity. The estimated global
prevalence of heavy episodic alcohol use among the adult population was 18.4% in 2015. Similarly, the prevalence
of tobacco smoking, cannabis use, and opioid use was 15.2%, 3.8%, and 0.37%, respectively. 6 The morbidity
measured in terms of disability-adjusted life-years (DALYs) was highest for tobacco smoking followed by alcohol
use and illicit drug use.
2. in India, substance use disorders have a weighted prevalence of 22.4%, with tobacco use disorders (20.89%) and
alcohol use disorders (4.64%) leading the numbers, according to the latest National Mental Health Survey of India.
The Normal Sexual Cycle and Sexual Dysfunction
The human sexual response cycle can be divided into 4 phases: excitement (desire and arousal), plateau, orgasm, and
resolution.8 There is a transition from one phase to another in the presence of an erotic stimulus. The phases are
influenced by the complex interplay of endocrine and nervous (central and autonomic) systems. Sexual dysfunction
can occur in any of these phases. Common sexual dysfunctions include hypoactive sexual desire disorder, erectile
disorder, premature (early) ejaculation, delayed ejaculation in men, and female sexual interest/arousal disorder,
female orgasmic disorder, genito-pelvic pain/penetration disorder in women. Substance/medication-induced sexual
dysfunction, other specified sexual dysfunction, and unspecified sexual dysfunction form the remaining categories
of sexual dysfunction.9 Different substances of abuse can affect any of these stages to cause sexual dysfunction.
Use of Specific Substances and Related Sexual Dysfunction
1. Sexual dysfunction in the context of substance use is not only caused due to the direct effects of the substances but
is also influenced by psychosocial and cultural contexts, comorbid psychiatric and medical illnesses, as well as
treatmentemergent side effects. The information regarding sexual problems may not be shared voluntarily and
sometimes the patient may be unaware of the same. It takes a careful and detailed sexual history to elicit various
aspects of sexual dysfunction. This should be done while making sure that the patient is comfortable and ensuring
confidentiality. The clinician should inquire into various aspects of the patient’s presenting complaints, including the
specific symptoms, onset, duration and progression of the symptoms, symptom severity, any related exacerbating or
relieving factors. The impact of current symptoms on the patient’s life as well as on the attitude towards treatment,
any interpersonal issues with the partner caused by current problems, as well as any treatment sought or self-
medication should be explored. Past sexual history including first sexual contact, knowledge about sexual
functioning as well as the history of sexual abuse will also add important information to the assessment and
management plan. A history of high-risk sexual behavior is an inevitable part of sexual history
1. Approach to Management
2. Feedback About the Relationship Between Substance Use and Sexual Dysfunction
3. Assessment of Other Causes for Sexual Dysfunction It is important to look for any organic causes of sexual
dysfunction during assessment.21 This would include, apart from a detailed history, a thorough general physical and
systemic examination
4. Psychosocial Management After the assessment, interventions need to be tailored according to the patient’s needs.
Educating the patient and partner about the risks of substance use and its effects on sexual function is very
important. This includes providing knowledge about the anatomy and physiology of normal sexual function, sexual
response cycle, and addressing their doubts and myths about sexual function. Therapy may include improving
communication patterns between the couple, improving awareness, and sensate focus therapy
1. Pharmacological Management In men, phosphodiesterase 5 inhibitors are found to be beneficial for the erectile
dysfunction and can be used on an as-needed basis without serious long-term side effects. Alternatively,
intracavernosal injections and non-pharmacological modalities like vacuum devices are also available.
2. The utility of testosterone replacement for erectile dysfunction or sexual desire is limited. Whenever prescribed, it
can be given under supervision or as transdermal preparations to avoid inappropriate use. Selective serotonin
reuptake inhibitors (SSRIs) such as fluoxetine and paroxetine are beneficial for premature ejaculation.
3. Other preparations include the use of local anesthetic like lignocaine and techniques like Master and Johnson
squeeze technique. In women, systemic testosterone can be considered for hypoactive sexual desire. However, it is
associated with side effects such as hirsutism, hoarseness of voice, alopecia, and a potential increase in
cardiovascular diseases which limits the utility of testosterone treatment. Topical estrogens can improve the vaginal
lubrication and genital arousal.
Paraphilic Disorders
Paraphilic disorders are a group of mental health conditions that cause recurring and intense sexual arousal to atypical
thoughts, fantasies, and behaviors. These disorders involve clinically significant distress or impairment in
functioning.1
Sex is a normal part of life, and having unconventional sexual thoughts and fantasies isn’t unusual. However, when these
urges and thoughts become so intense as to interfere with your daily functioning, it may be a paraphilic disorder.
People with paraphilic disorders will often engage in sexual behaviors that can cause harm to themselves and others.
Some paraphilias focus explicitly on causing pain and suffering to oneself or others.
Not all paraphilic interests make up a paraphilic disorder. It’s important to distinguish between paraphilia and a
paraphilic disorder. While the former includes unusual sexual urges and behaviors, the latter features paraphilic
symptoms that cause distress or impairment to the individual or the risk of harm to yourself or others.
Identifying Paraphilic Disorders
It’s important to note that there’s a distinct difference between paraphilias and paraphilic disorders. Paraphilias can be
harmless if they aren’t causing harm or distress to yourself or others. If there’s a risk of harm, it could also be
classified as a paraphilic disorder. For unknown reasons, paraphilias appear more common in men than women. 3 To
be diagnosed with a paraphilic disorder, the DSM-5 requires the following criteria to be met: 4
Feeling personal and not just societal distress as a result of your sexual interests urges, and behaviors
Experiencing sexual desire that could cause physical harm or psychological distress to another person
A desire to engage in sexual behaviors with non-consenting parties or people who cannot give consent
Causes of Paraphilic Disorders
It’s a little unclear what exactly causes paraphilic disorders. Scientists and researchers suspect that a combination of
neurobiological, genetic, developmental, behavioral, and interpersonal factors play a role. In a 2019 study on
paraphilic disorders, researchers observed that people with paraphilic disorders have elevated levels of serotonin
and norepinephrine and decreased levels of a metabolite of dopamine called dihydroxyphenylacetic acid (DOPAC).
1. Treatment for Paraphilic Disorders
2. Treatment for paraphilic disorders is highly individualized. It depends on various factors, including which type of
paraphilic disorder you have and the personal goals of the person being treated. In general, different forms of
therapy and medications are used in treating paraphilic conditions. A combination of psychotherapy and medication
is often recommended for the most effective results.
Medication
Medication approaches to paraphilic disorders may help people control their sexual arousal or behavior. Antiandrogen
treatment is may be a pharmacological treatment for men with severe paraphilic disorders. Antiandrogen treatments
are particularly recommended for paraphilic disorders that can cause harm to others or lead to sexual offenses.
Antiandrogen treatments work by reducing testosterone which in turn reduces sexual drive. In mild cases, selective
serotonin reuptake inhibitors may be prescribed. 12 There’s currently no medication explicitly approved for the
treatment of paraphilic disorders.
Psychotherapy
Psychotherapy may help someone manage or cope with their paraphilic symptoms and behaviors. Cognitive behavioral
therapy (CBT) has been the most commonly used approach for paraphilic disorders. 1
Exhibitionist disorder
1. Exhibitionism involves exposing the genitals to become sexually excited or having a strong desire to be
observed by other people during sexual activity. Exhibitionistic disorder involves acting on exhibitionistic
urges or fantasies or being distressed by or unable to function because of those urges and fantasies.
Most exhibitionists do not have exhibitionist disorder.
Doctors diagnose exhibitionist disorder when people feel greatly distressed or become less able to function well because
of their behavior, or they have acted on their urges with a person who does not consent.
Treatment, which usually begins after exhibitionists are arrested, includes psychotherapy, support groups, and certain
antidepressants.
2. Exhibitionists (usually males) expose their genitals, usually to unsuspecting strangers, and become sexually excited
when doing so. They may be aware of their need to surprise, shock, or impress the unwilling observer. The victim is
almost always a woman or a child of either sex. Actual sexual contact is almost never sought, so exhibitionists rarely
commit rape.
Although the true prevalence of exhibitionistic disorder is unknown, it is about 2 to 4% in men and appears to be much
lower in women.
Exhibitionism usually starts during adolescence, but occasionally the first act can occur during preadolescence or middle
age. Most exhibitionists are married, but the marriage is often troubled.
About 30% of male sex offenders who are arrested are exhibitionists. They tend to persist in their behavior. About 20 to
50% are re-arrested.
Exposure of genitals to unsuspecting strangers for sexual excitement is rare among women. Women have other venues to
expose themselves: dressing provocatively (which is increasingly accepted as normal) and appearing in various
media and entertainment venues. Participation in these venues of itself does not constitute a mental health disorder.
For some people, exhibitionism is expressed as a strong desire to have other people watch their sexual acts. Such people
want to be seen by a consenting audience, rather than to surprise people. People with this form of exhibitionism may
make pornographic films or become adult entertainers. They are rarely distressed or impaired by their desire and
thus may not have a mental health disorder.
Most people with exhibitionistic tendencies do not have a disorder.
Exhibitionists may have a coexisting personality disorder (usually antisocial) or conduct disorder.
A doctor's evaluation, based on standard psychiatric diagnostic criteria
Doctors diagnose exhibitionistic disorder when
People have been repeatedly and intensely aroused by exposing their genitals or being observed by other people during
sexual activity, and the arousal has been expressed in fantasies, intense urges, or behaviors.
As a result, people feel greatly distressed or become less able to function well (at work, in their family, or in interactions
with friends), or they have acted on their urges with a person who does not consent.
They have had the condition for 6 months or more.
In diagnosing exhibitionistic disorder, the doctor also specifies whether the person is sexually aroused by
The DSM-5 criteria for exhibitionistic disorder includes the following:
The individual’s compulsive exhibitionistic behaviors must consistently occur over a six-month period
The act and desire to show their genitals to nonconsenting strangers results in extreme sexual arousal
Their exhibitionistic behavior causes them acute distress
Their social life, career, and ability to function are disrupted by their compulsive desires
Other mental and physical conditions have been ruled out
What Causes Exhibitionist Behavior?
Some of the risk factors for developing exhibitionistic disorder include past sexual abuse, antisocial personality disorder,
alcohol or substance use, and interest in pedophilia. The prevalence rate for exhibitionistic disorder is unknown but
occurs almost exclusively in males. Exhibitionistic disorder is considered rare among females.
Regardless of gender, some people express exhibitionism healthily; it’s simply a kink. Perhaps they have a strong desire
for other people to watch them have sex or become sexually stimulated. But in these instances, people want a
consenting audience or individual involved, rather than exposing themselves to distraught victims.
Is Exhibitionism a Crime?
Depending on the nature of the offense, exhibitionism can be considered a criminal offense. Individuals with
exhibitionistic disorder may be charged with and convicted of:
Indecent exposure
Sexual assault
Public indecency
Indecency with a child by exposure
Other crimes, depending on their severity and the circumstances involved
Treatment of Exhibitionistic Disorder

Therapeutic Options
Sex therapy may be highly effective in helping someone to identify things that cause their exhibitionist urges and can
teach them effective skills to deal with those urges and desires in healthier ways.
Cognitive behavioral therapy (CBT) treatment usually includes cognitive restructuring, which helps the individual in
identifying and changing the thoughts that cause the behavior.
Group therapy for adults may also be beneficial. One of the best aspects of group therapy is that someone with
exhibitionistic disorder will realize that they’re not alone in their struggle and that others will help support them in
their recovery. Family therapy and relationship therapy treatment are also common and can help the
exhibitionist’s loved ones to better understand and support them
Psychiatric Treatment Options
Several types of medications can be used to lessen sexual desire, most of which are antidepressant drugs. Selective
serotonin reuptake inhibitors (SSRIs) that are used for depression and other mood disorders may be prescribed to
reduce the exhibitionist’s libido—helping the cognitive restructuring process (from CBT treatment) to be more
effective. Anti-androgens may also help relieve exhibitionistic disorder’s compulsive tendencies by directly
lowering testosterone levels in the body.
Voyeuristic Disorder
1. Voyeurism involves becoming sexually aroused by watching an unsuspecting person who is disrobing, naked,
or engaged in sexual activity. Voyeuristic disorder involves acting on voyeuristic urges or fantasies or being
distressed by or unable to function because of those urges and fantasies.
Most voyeurs do not have voyeuristic disorder.
Doctors diagnose voyeuristic disorder when people feel greatly distressed or become less able to function well because
of their behavior, or they have acted on their urges with a person who has not consented.
Treatment, which usually begins after voyeurs are arrested, includes psychotherapy, support groups, and certain
antidepressants.
Voyeurism usually begins during adolescence or early adulthood. Some degree of voyeurism is common, more among
boys and men but increasingly among women. Society often regards mild forms of this behavior as normal when
involving consenting adults. Privately viewing sexually explicit pictures and shows available on the internet is not
considered voyeurism because it lacks the element of secret observation, which is the hallmark of voyeurism.
However, the miniaturization of surveillance cameras and the widespread use of cell phone cameras have given rise
to video voyeurism, which involves the filming of nonconsenting persons disrobing or engaged in sexual activity.
This activity is increasingly common and is generally considered a crime in most countries.
Voyeuristic disorder is one of the most common paraphilias and is much more common among men. The ratio of male to
female voyeurs is between 2:1 and 3:1. What little is known about voyeuristic disorder is largely gleaned from
people who have been imprisoned for this behavior. Many offenders may also be hypersexual and have any or a
number of other mental health conditions, including exhibitionistic disorder, depression, conduct disorder, or
antisocial personality disorder.
When voyeurism is a disorder, voyeurs spend a lot of time seeking out viewing opportunities. As a result, they may
neglect important aspects of their life and not fulfill their responsibilities. Voyeurism may become the preferred
method of sexual activity and consume countless hours of watching.
Diagnosis of Voyeuristic Disorder
Doctors diagnose voyeuristic disorder when
People have been repeatedly and intensely aroused by observing an unsuspecting person who is naked, undressing, or
engaging in sexual activity, and the arousal has been expressed in fantasies, urges, or behaviors.
with friends), or they have acted on their urges with a person who has not consented.
What Causes Someone to Develop Voyeuristic Disorder & Other Sexually Deviant Behaviors?
While there is no conclusive evidence regarding the causes and triggers of voyeuristic disorder, it has been linked to
childhood sexual abuse, substance misuse, and hypersexuality. Ultimately, there is no conclusive evidence regarding
causation or prevalence of co-occurrence. Typically, voyeuristic behavior develops during adolescence; however,
voyeurism isn’t recognized as a mental health diagnosis until adulthood, as the disorder may be difficult to discern
from normative and age-appropriate sexual curiosity. 1
.
Treatment of Voyeuristic Disorder
Sex Therapy
Receiving sex therapy from a certified sex therapist who specializes in paraphilias will ensure a knowledgeable and non-
judgmental approach to treating a voyeuristic disorder. They will likely offer coaching on mindfulness and
behavioral techniques that either an individual or couple can explore. Co-occurring psychological conditions, such
as mood disorders or hypersexuality, will also be assessed and treated.
Cognitive Behavioral Therapy (CBT)
Sex therapists with CBT training will employ cognitive restructuring techniques to identify and change thoughts and
behaviors. They may utilize aversion therapy or guided imagery to reduce interest in voyeuristic behavior. Studies
have shown CBT to be an effective treatment for this disorder, particularly when utilized in conjunction with drug
therapy.
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) such as Prozac (fluoxetine) can help with co-occurring mood disorders,
such as depression or anxiety, while simultaneously lowering sex drive. A lowered sex drive can help with the
impulsivity associated with voyeuristic thoughts and behaviors; however, without therapy, this does not directly
address the voyeuristic urge.
Antiandrogens
Medroxyprogesterone acetate and cyproterone acetate are members of a class of drugs that can be used to temporarily
lower circulating testosterone levels. Doing this reduces sex drive and allows for more effective therapy techniques
and cognitive restructuring.
Support Groups
Attendance of a support group or therapy group can augment the effectiveness of other treatment approaches as well.
Connecting with others who experience similar urges may reduce social stigma and isolation, and improve your
ability to integrate coping skills.
.
.
. Frotteurism is intense sexual arousal from touching or rubbing against a nonconsenting person. Frotteuristic
disorder is diagnosed when a person has acted on these sexual urges or the urges cause significant distress or
impaired functioning.
Causes of frotteuristic disorder are thought to include a combination of psychological, social, and biological factors.
A doctor diagnoses frotteuristic disorder in a person who experiences recurrent and intense sexual arousal from touching
or rubbing against a nonconsenting person or has acted on those urges.
Treatment combines individual or group psychotherapy with antidepressants known as selective serotonin reuptake
inhibitors (SSRIs) and other medications
The word frottage comes from the French frotter, which means "to rub or to put pressure on someone." The term is now
used to describe intense sexual arousal as a result of touching (nongenitally) or rubbing one’s genital area against a
nonconsenting person. This usually involves contact with an unknown person in crowded areas such as subways,
buses, elevators, sporting events, or other crowded public events.
Many frotteurs appear to be excited by the risk of getting caught in a public place. Most cases of frotteurism occur with
males touching females, although there have been cases of females touching males or females or males touching
males. There have also been cases of adults of either sex touching children. When this behavior is committed by
adults, it is considered a crime because it is a form of nonconsensual sex.
.
. Frotteurism is intense sexual arousal from touching or rubbing against a nonconsenting person. Frotteuristic
disorder is diagnosed when a person has acted on these sexual urges or the urges cause significant distress or
impaired functioning.
Causes of frotteuristic disorder are thought to include a combination of psychological, social, and biological factors.
A doctor diagnoses frotteuristic disorder in a person who experiences recurrent and intense sexual arousal from touching
or rubbing against a nonconsenting person or has acted on those urges.
Treatment combines individual or group psychotherapy with antidepressants known as selective serotonin reuptake
inhibitors (SSRIs) and other medications
The word frottage comes from the French frotter, which means "to rub or to put pressure on someone." The term is now
used to describe intense sexual arousal as a result of touching (nongenitally) or rubbing one’s genital area against a
nonconsenting person. This usually involves contact with an unknown person in crowded areas such as subways,
buses, elevators, sporting events, or other crowded public events.
Many frotteurs appear to be excited by the risk of getting caught in a public place. Most cases of frotteurism occur with
males touching females, although there have been cases of females touching males or females or males touching
males. There have also been cases of adults of either sex touching children. When this behavior is committed by
adults, it is considered a crime because it is a form of nonconsensual sex.
.
Diagnosis
A doctor diagnoses frotteuristic disorder based on the following criteria:
The person experiences recurrent and intense sexual arousal from touching or rubbing against a nonconsenting person (in
fantasies, urges, or behaviors).
The person has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause distress or
impairment in social, occupational, or other important areas of functioning.
The condition has been present for 6 months or more.
The doctor must also specify whether the person is living in a controlled environment (for example, an institution) or in
full remission (has had at least 5 years without distress/impairment in an uncontrolled environment).
Is Frotteurism Illegal?
Yes, forcing oneself on a non-consenting stranger is illegal. However, it is unusual for frotteurs to be arrested or face
legal consequences as they typically leave the scene immediately after initiating non-consenting touch. 2 The more
exclusively an individual’s arousal centers on the act of touching or rubbing against a non-consenting person, the
more likely it is that these urges will cause illegal or inappropriate behavior to occur.
.
Causes & Triggers of Frotteuristic Disorder
Some professionals theorize that accidental touch that leads to sexual arousal in childhood or adolescence may cause
frotteuristic fantasies later in life. While children and adolescents may touch or rub against unwilling participants,
sexual motivation tends to be less clear, and frotteuristic disorder is not a typical diagnosis until late adolescence or
adulthood.
Both antisocial behavior and hypersexuality have been linked to frotteuristic disorder, although causality has not been
determined. Depression, anxiety, and low self-esteem have been linked to frotteuristic disorder. 4 People with
frotteuristic disorder tend to be isolated and have difficulty finding consenting sexual or romantic partners.
Substance use, particularly involving stimulants such as cocaine and amphetamines may lead to frotteuristic episodes;
however, unless someone also experiences frotteuristic fantasies, urges, or behaviors when not intoxicated,
frotteuristic disorder is not an appropriate diagnosis.
.
Treatment of Frotteuristic Disorder
Sex Therapy
Antidepressants
Antiandrogens
Group Therapy
Frotteuristic Disorder Statistics
Here are additional statistics on frotteuristic disorder: 1
Frotteuristic behavior occurs in up to 30% of adult males
Frotteuristic disorder occurs in approximately 10-14% of adult males seen in outpatient settings for paraphilic disorders
Frotteuristic disorder occurs almost exclusively in men
Frotteuristic fantasies and behavior may decrease with age
In one study, approximately 24% of women reported being a victim of frotteuristic behavior in their lifetime 3
Frotteuristic disorder typically develops during late adolescence or early adulthood
Sex Therapy
therapy.
Antidepressants
Sex Therapy
therapy.
Antidepressants
Sexual masochism disorder
.
Sexual masochism involves acts in which a person experiences sexual excitement from being
humiliated, beaten, bound, or otherwise abused. Sexual masochism disorder is sexual
masochism that causes significant distress or substantially interferes with daily functioning.
Some amount of sadism and masochism is commonly play-acted in healthy sexual relationships, and
mutually compatible partners often seek one another out. For example, the use of silk handkerchiefs for
simulated bondage and mild spanking during sexual activity are common practices between consenting
partners and are not considered sadomasochistic.
Most people who engage in masochistic activities are open about their involvement in BDSM (bondage-
domination-sadism-masochism) activities. Most interact with a consenting partner, who may have
sexual sadism (that is, who experiences sexual excitement from inflicting physical or psychological
suffering on another person). In these relationships, the humiliation and beating are simply acted out, with
participants knowing that it is a game and carefully avoiding actual humiliation or injury, often by using a
prenegotiated "safe word." However, some masochists increase the severity of their activity with time and
may stop using their safe word as way to protect themselves, which can potentially lead to serious injury
or death.
. in contrast, sexual masochism disorder involves the following:
People are distressed by their behavior or unable to function because of their behavior.
Acts result in severe bodily or psychological harm and even death, as can occur in asphyxiophilia.
The person has been living with the condition for 6 months or more.
Asphyxiophilia (autoerotic asphyxiation)

Asphyxiophilia is considered a subtype of sexual masochism disorder. People with asphyxiophilia partially choke or
strangle themselves by applying a noose around their neck during masturbation, or they allow a partner to do so.
Typically, people use articles of clothing (such as scarves or underwear) as the noose. They may attach the noose to an
object in the room (such as a doorknob or bedpost). A temporary decrease in oxygen to the brain at the point of
orgasm is sought as an enhancement to sexual release, but the practice may accidentally result in brain damage or
death.
Sexual Masochism Disorder Vs. Masochistic Behavior & BDSM
A person with masochistic interests fantasizes about or engages in sexual activity that involves being humiliated, beaten,
bound, or otherwise made to suffer. Consenting sexual play involving the experience of humiliation or pain doesn’t
classify as sexual masochism disorder; however, it is important to assess whether adequate safety measures are in
place.
BDSM incorporates a variety of erotic practices, sexual preferences, and behaviors, including bondage, unequal power
relationships, and/or the exploration of pain as an erotic element. People who identify as BDSM practitioners or
sexual masochists but do not report distress, impairment, or non-consensual harm to self or others are not classified
as having a disorder.
Is Sexual Masochism Dangerous?
Sexual masochism can potentially be dangerous, particularly if asphyxiophilia is involved. Any form of inflicted pain
carries some degree of risk. Everyone should be aware of their own physical health and the boundaries established
within the sexual relationship. With that, it’s important to note that sexual masochism can certainly also be practiced
consensually and safely, and it does not need to be stigmatized.
Symptoms of Sexual Masochism Disorder
The main criterion for sexual masochism disorder is a recurrent and intense sexual arousal from the act of being
humiliated, beaten, bound, or otherwise made to suffer. This desire can be manifested by fantasies, urges, or
behaviors. A person with sexual masochism disorder is often only able to achieve arousal when pain or suffering is
present and they may lack control over their fantasies, urges, or behaviors. 1
In order to meet the diagnostic criteria for sexual masochism disorder in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), there are specific criteria that must be met.
To be diagnosed, symptoms of sexual masochism disorder must:
Be present for at least six months
Involve recurrent and intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer,
as manifested by fantasies, urges, or behaviors
Involve sexual urges or fantasies that cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning
Why Do People Engage in Sexual Masochism?
While there is no conclusive evidence regarding what causes or triggers sexual masochism disorder, the
extensive use of pornography involving the act of being humiliated, beaten, bound, or otherwise made to suffer is
sometimes an associated feature of sexual masochism disorder. 1 Also, while other psychiatric disorders may be
diagnosed along with sexual masochism disorder, this does not prove a direct causation.
Sexual masochism disorder typically develops in young adulthood. The average age of onset reported by diagnosed
individuals is 19.3 years. However, it is not unusual for diagnosed individuals to have experienced sexually
masochistic fantasies in puberty or childhood. Advancing age is likely to reduce symptoms of the disorder. 1
There is no increased prevalence of having experienced childhood sexual abuse among those who are diagnosed with
sexual masochism disorder.2
Are Men or Women More Likely to Engage in Sexual Masochism?
It’s estimated that sexual masochism disorder impacts 1-5% of the general population, but exact studies on the
prevalence of sexual masochism among men and women are difficult to find. One study found that 4.8% of men and
2.1% of women obtained sexual pleasure from inflicting pain, whereas 2.5% of men and 4.6% of women obtained
pleasure from receiving pain.4
Treatment of Sexual Masochism Disorder
Sex Therapy
The therapist may also assess and focus on:
Safety planning and harm reduction to employ when engaging in BDSM activities
Skills for navigating urges as they arise and mindfulness exercises or self-soothing techniques for reducing distress
Co-occurring psychological conditions, such as mood disorders or hypersexuality
Cognitive Behavioral Therapy
Cognitive-behavioral therapy (CBT) may be beneficial for people wishing to reduce or eliminate certain sexual
behaviors. CBT highlights the interconnected relationship between thoughts, feelings, and behaviors. By learning
how to change unwanted or intrusive thoughts, people can feel more empowered in how they choose to respond.
Over time, this can lead to profound change.
Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) can help with co-occurring mood disorders,
such as depression or anxiety, while simultaneously lowering sex drive. Antiandrogens
Medroxyprogesterone acetate and cyproterone acetate are members of a class of drugs which can be used to lower
testosterone levels temporarily in order to reduce sex drive and allow for more effective therapy.
Sexual sadism involves acts in which a person experiences sexual excitement from inflicting physical or
psychological suffering on another person. Sexual sadism disorder is sexual sadism that causes significant
distress, substantially interferes with daily functioning, harms another person, or involves someone who has
not given consent.
Most sadists interact with a consenting partner, who may have sexual masochism (that is, he or she experiences sexual
excitement from being humiliated, beaten, bound, or otherwise abused). In these relationships, the humiliation and
beating are simply acted out, with participants knowing that it is a game and carefully avoiding actual humiliation or
injury. Fantasies of total control and dominance are often important, and sadists may bind and gag their partner in
elaborate ways.
In contrast, sexual sadism disorder involves the following:
People are distressed by their behavior or unable to function because of their behavior.
They take these acts to an extreme, sometimes causing severe bodily or psychological harm or even death.
The acts involve partners who do not give their consent (nonconsenting partners).
The condition has been present for at least 6 months.
When practiced with nonconsenting partners, sexual sadism is considered a crime and is likely to continue until the
sadist is apprehended.
Sexual sadism is not synonymous with rape, a complex mixture of coerced sex and power exerted over the victim. Sexual
Consenting Sadistic Acts Vs. Sexual Sadism Disorder
Consenting sexual play involving the infliction of pain does not classify as sexual sadism disorder. Sexually active adults
may engage in consenting “rough sex” or be aroused by sexual acts involving the infliction of pain. In the absence of
fixation, mental distress, or the non-consenting infliction of pain on another person, this arousal would not be
classified as sexual sadism disorder.
In order to meet the diagnostic criteria for sexual sadism disorder, the sexually sadistic focus must have: 1
Been present for at least six months .
Involved recurrent and intense sexual arousal from the physical or psychological suffering of another person, as
manifested by fantasies, urges, or behaviors.
Included the individual acting on these urges with a non-consenting person.
AND/OR: The sexual urges or fantasies have caused clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Other Specifiers of Sexual Sadistic Disorder
Sexual sadistic disorder may be specified as:
In a controlled environment, when an individual lives in an institution or other setting where opportunities to engage in
sadistic sexual behaviors are restricted.
In full remission, when the individual has not acted on urges with a non-consenting person, and there has been no
distress or impairment in social, occupational or other areas of functioning for at least five years while in an
uncontrolled environment.
Causes & Triggers of Sexual Sadism Disorder
Sexual sadism disorder typically develops in young adulthood. The average age of onset in one study of sadistic males
was 19.4 years.1 Advancing age is likely to have the same reducing effect on this disorder as it has on other
paraphilic disorders.
Some studies show that temporal lobe abnormalities may be implicated in sexual sadism, but more information is needed
before any strong conclusions can be made. 2 There is no conclusive evidence regarding what causes or triggers
sexual sadism disorder. While other psychiatric disorders may be diagnosed along with sexual sadism disorder, this
does not demonstrate causation.
How Is Sexual Sadism Disorder Diagnosed?
Sexual sadism disorder is most often diagnosed through mandated psychological treatment following the perpetration of
assault on a non-consenting person or people. Sexual sadism disorder may also be identified through self-report of
distressing urges, fantasies, or behavior to a mental health clinician.
Many people who experience sexual excitement from the psychological or physical infliction of suffering on another
person do not experience distress due to this excitement or act on their urges with unwilling participants. For those
who do experience distress at the source of their arousal, a mental health clinician may find that criteria have been
met to classify these urges as a psychological disorder. 1
Treatment of Sexual Sadism Disorder
Sex Therapy
Sex therapy with a certified sex therapist who specializes in paraphilias will ensure a knowledgeable and non-judgmental
approach to therapy. A sex therapist will take a detailed sexual and psychosocial history to assess for factors that
contribute to the sadistic interest and its expression through urges, fantasies, and behaviors
behaviors. They may utilize aversion therapy or guided imagery to reduce interest in sadistic fantasies and change
masturbatory habits.
Antidepressants
Selective Serotonin Reuptake inhibitors (SSRIs) such as Prozaccan help with co-occurring mood disorders, such as
depression or anxiety, while simultaneously lowering sex drive. Antiandrogens
Medroxyprogesterone acetate and cyproterone acetate are members of a class of drugs which can be used to lower
testosterone levels temporarily in order to reduce sex drive and allow for more effective therapy. These drugs help
reduce the levels of circulating testosterone and prime the recipient for cognitive restructuring therapy techniques. 2
Pedophilic disorder
Pedophilic disorder is characterized by recurring, intense sexually arousing fantasies, urges, or behavior involving
children (usually 13 years old or younger).
Pedophiles may be attracted to young boys, young girls, or both, and they may be attracted only to children or to children
and adults.
Doctors diagnose pedophilia when people feel greatly distressed or become less able to function well because of their
attraction to children or when they have acted on their urges.
Treatment involves long-term psychotherapy and medications that alter the sex drive and reduce testosterone levels
Whether sexual interest or involvement between two people is considered pedophilic disorder depends on the age of the
people involved. In Western societies, a diagnosis of a pedophilic disorder requires that the person be 16 years old or
older and at least 5 years older than the child who is the object of the sexual fantasies or activity. However, sexual
involvement of an older adolescent (aged 17 to 18) with a 12- or 13-year-old may not be considered a disorder. The
age criteria used to identify when such activity is considered a crime may differ across cultures.
Pedophilic disorder
Relevant Pedophilia Statistics
Here are several relevant statistics concerning pedophilia:
Research indicates that approximately 3-5% of the population experience pedophilic attraction 12
The vast majority of people experiencing pedophilia are male, with only 3% of women exhibiting sexual interests in
children11
Studies have documented that the majority of individuals who commit sexual offenses against children do not necessarily
experience a romantic or sexual attraction to them 12
Approximately 46% of individuals with pedophilic interests consider suicide: 32% report having a plan and 13% attempt
suicide13
About 41% of minor-attracted individuals who consider suicide do so before the age of 18 12
Approximately 85% of people with pedophilic interests expect to be misunderstood by treatment providers; 89% expect
to be judged’ and 76% fear that their confidentiality will be compromised 13
Pedophilic disorder
What Causes Pedophilia?
The causes of pedophilic attraction remain largely misunderstood by the general public and the scientific
community.14 While no direct causal relationship can be determined, researchers have linked the development of
pedophilic interests to a number of environmental and neurobiological factors. For example, some early
investigations document a higher prevalence of childhood sexual abuse among people with pedophilic interests.
Factors linked to pedophilia include:
Pathological or dysfunctional family systems
Absence of social support in childhood
Developmental disruptions
Certain neurobiological factors
Certain biological factors
Pedophilic disorder
Biological Factors of Pedophilia
Recent developments in neurobiology are increasingly leading to an expansion of scientific knowledge regarding the
potential causes of pedophilia, but there still are no definitive answers as to what exactly causes this condition. 15,16
Here are some of the prominent findings from investigations on neurological and biological factors associated with the
development of sexual attraction to children:
According to research, early brain development seems to play a crucial role in the development of pedophilic interests 17,18
Temporal lobe and frontal cortex abnormalities have been observed among pedophilic individuals. These regions of the
brain are critical for sexual and behavioral regulation, impulse control, and executive functions 15
Reduction of gray matter in the amygdala and hypothalamus have been found in pedophilic populations. These regions
of the brain are responsible for sexual development 19
Atypical physiological development before birth has been found in large samples of men exhibiting attraction to
children20
Anatomical differences such as left-handedness and other superficial deviations from typical physiological development
have been implicated in the development of pedophilic interests 20,21
Research has reported an association between intelligence and pedophilia. Specifically, lower IQ levels have been found
in samples of pedophilic individuals 17
Genetic alterations that are linked to androgen, estrogen, prolactin, oxytocin, corticotropin, and serotonin have been
Pedophilic disorder
Symptoms of Pedophilia
A diagnosis of pedophilia should specify whether someone is exclusively attracted to children or if they also experience
attraction to same-age individuals. Additional specifications should consider the gender of children and if the
person’s sexual interest or behavior is limited to incest (sexual attraction or behavior toward a young family
member).1
The three official symptoms of pedophilia are: 1
Persistent and recurrent sexually arousing fantasies, urges, or behaviors involving a prepubescent child experienced for at
least six months
Significant distress or interpersonal challenges caused by sexual fantasies and urges involving a prepubescent child
Having committed an actual sexual offense against a child.
How Is Pedophilia Diagnosed?
The initial step to diagnosis involves an assessment with a qualified licensed helping professional, such as a clinical
social worker, professional counselor, psychologist, or psychiatrist. Preferably, the practitioner has also received
formal training in human sexuality and holds a specialized certification in sex therapy.
Note that a diagnosis of pedophilia should not be given to anyone 16 or younger. Diagnosis should also be avoided when
an individual in late adolescence (16 or 17 years-old) is involved in an ongoing sexual relationship with a peer
approximately four years younger.
Pedophilic disorder
Treatment for Pedophilia
Ethical, compassionate, and competent treatment for minor-attracted individuals should focus on both sexual abuse
prevention and client well-being. 23 Although no single treatment exists that offers a cure for pedophilia, several
interventions have shown promise at reducing the intensity of sexual urges, improving psychosocial functioning, and
decreasing risk of sexual offending
Cognitive-behavioral Therapy (CBT)
Psychodynamic Therapy
Psychodynamic therapy may be a more appropriate option for people wishing to explore childhood traumas, early sexual
development, and personality structures. 19 From this perspective, pedophilic interests reflect unresolved conflicts
that stem from disruptions during the period of psychosexual development (infancy through prepuberty).
Relapse Prevention
Relapse prevention is generally used in treatment for people who have already committed sexual offenses. This approach
focuses on eliminating risk factors associated with sexual abuse of children. 25 Individuals learn to anticipate
emotional and behavioral triggers, as well as risk situations (e.g., viewing child pornography) that could precipitate
sexual offending.
.
Pedophilic disorder
Strengths-Based Approaches to Therapy
Strengths-based therapists are trained to understand and appreciate the influence of the environment in identity
development. Strengths-based therapy with minor-attracted individuals fosters discussions about social stigma and
its impact on their emotional and psychosocial well-being. 27 While a strengths-based perspective can be integrated
into most types of psychotherapies, some are more naturally suited to this approach, such as narrative therapy and
compassion-focused therapy.
SSRIs
Selective Serotonin Reuptake Inhibitors (SSRIs) are often prescribed to help decrease sexual desire, sexual urges, and
compulsive sexual behavior. This method is most commonly used with individuals who have been convicted of a
sexual crime, aligning with the main objective to reduce sexual recidivism risk. 28 Minor-attracted individuals may
choose to take SSRIs to treat anxiety or depression symptoms, as well as to contain sexual urges or reduce risk of
sexual high-risk behaviors.25
Antiandrogens
Though controversial, chemical castration is another judicial response to manage severe cases of sexual offending. It
intends to lower testosterone levels through administration of antiandrogen steroid hormones. Some states have
specific laws that require individuals convicted of serious sexual crimes to receive this treatment. 28
Fetishistic disorder
Fetishism is use of an inanimate object (the fetish) as the preferred way to produce sexual arousal. Fetishistic
disorder occurs when recurrent, intense sexual arousal from using an inanimate object or focusing on a
nongenital body part (such as a foot) causes significant distress, substantially interferes with daily functioning,
or harms or may harm another person.
People with fetishes may become sexually stimulated and gratified in various ways, such as the following:
Wearing another person's undergarments
Wearing rubber or leather
Holding, rubbing, or smelling objects, such as high-heeled shoes
If sexual arousal occurs mainly from wearing clothing of the opposite sex (that is, cross-dressing) rather than using the
clothing in some other way, the paraphilia is considered transvestism.
People with fetishistic disorder may not be able to function sexually without their fetish. The fetish may replace typical
sexual activity with a partner or may be integrated into sexual activity with a willing partner. The need for the fetish
may be so intense and compulsive that it becomes all-consuming and destructive in a person's life. But in most
people who have a fetish, their behavior does not meet the criteria for a disorder because it does not cause them
significant distress, interfere with daily functioning, or harm others.
What Is a Fetish?
A fetish involves the repetitive use or dependence on a non-living object (shoes, leather) and/or a traditionally non-sexual
body part (feet, hair) in order to achieve sexual satisfaction. Sexual fetishes frequently include both inanimate
objects and body parts (legs in latex, feet in boots). The fetish object may create sexual arousal through any or all of
the senses, including feel, smell, or appearance. Over time, people may also acquire extensive collections of fetish
objects.
Fetishes involving inanimate objects fall into two general categories: form fetishes and media fetishes. Form fetishes
center on the size, shape, and appearance of an object, whereas media fetishes focus on the texture or feel of an
object. An object may fall into both categories, as is the case for a latex fetish—latex has both a specific appearance
and a unique texture. An individual’s fetish may focus on the form or media aspects of an object more strongly in
order to achieve sexual gratification.
How Common Is Fetishistic Disorder?
While many people have fetishes, the exact prevalence of people meeting the clinical criteria for fetishistic disorder is
unknown. This is likely due to the shame, stigma, and societal taboo surrounding paraphilias. However, research
shows that men are more likely to have this condition than women. 2
Common Types of Fetishes
There are countless kinds of fetishes. Feet, underwear, and shoes are among some of the most common types. Other parts
of the body, including hair, wearing certain kinds of makeup, body piercings, navels, noses, arms, and legs can also
be fetishized.
Examples of common fetishes include:
Lingerie
Leather
Certain clothing colors or materials
Costumes
Body fluids
Non-sexual objects used sexually
Symptoms of Fetishistic Disorder
The main symptom of fetishistic disorder is a recurrent and intense sexual arousal from either the use of nonliving
objects or a highly specific focus on nongenital body part(s), manifesting as fantasies, urges, or behaviors. A person
with fetishistic disorder may feel sexual shame and distress at the atypical focus of their sexual desire. 1
Symptoms of fetishistic disorder include: 1
Recurrent and intense sexual arousal from inanimate objects or nongenital body parts, persisting for at least six months
These feelings cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning
The fetish objects are not limited to objects or devices specifically designed for the purpose of genital stimulation (sex
toys, such as vibrators or dildos).
Sexually active adults may occasionally become aroused by objects or by traditionally non-sexual body parts, but in the
absence of fixation and mental distress, this attraction would not be classified as fetishistic disorder.
What Causes Fetishes to Develop?
Fetishes typically develop with the onset of puberty. Some theorists believe that fetishistic interests arise due to an object
or body part’s association with a person’s earliest experiences of sexual arousal or masturbation.There is no
conclusive evidence regarding what causes or triggers fetishistic disorder.
Impacts of Fetishistic Disorder on Individuals & Relationships
Fetishistic disorder commonly leads to shame and emotional distress in people who experience this type of arousal.
Internal conflict and fear of judgment can lead to isolation and difficulty finding or honestly communicating in
sexual relationships. Additionally, partners of those with fetishistic disorder may feel inadequate, unattractive or
worried about the implications of a fetishistic interest.
Sexual dysfunction often occurs when the fetishistic object is not present. erectile dysfunction (ED) or
delayed ejaculation (DE) may lead individuals or couples to seek treatment.
How Is Fetishistic Disorder Diagnosed?
Some people first come to terms with their fetishistic disorder via their own self-reporting or self-diagnosing. These
individuals can readily identify the distress associated with having their fetish, and have likely done some of their
own research. A mental health professional, such as a psychologist or therapist, can accurately diagnose fetishistic
disorder using the criteria outlined in the DSM-5.
Are Fetishes Normal?
Yes, sexual fetishes are quite normal, and many people have them. There is nothing inherently wrong or bad about
having fetishes, and they can be enjoyed within a consensual sexual relationship. Fetishes may emerge at any point
in time, but many people first notice them around puberty or late adolescence. They may evolve throughout
adulthood.
Kink Vs. Fetish
Although people sometimes use the terms interchangeably, a kink refers to a sexual preference that’s typically considered
less mainstream (although this is inherently subjective), but that someone doesn’t need to have this preference met to
receive sexual enjoyment. But when someone has a fetish, they generally rely on that fetish to become aroused or
achieve orgasm.
Treatment of Fetishistic Disorder
Sex Therapy
Antiandrogens
Transvestism involves recurrent, intense sexual arousal from cross-dressing. Transvestic disorder is transvestism
that causes significant distress or substantially interferes with daily functioning.
Most cross-dressers do not have a psychiatric disorder. They may be said to have transvestism rather than transvestic
disorder.
Doctors diagnose transvestic disorder only when people are greatly distressed by or cannot function well because of their
desire to cross-dress or because of interference in other areas of their lives by the time and expense spent engaging in
cross-dressing.
No medications are reliably effective, but psychotherapy, when needed, may help people accept themselves and control
behaviors that could cause problems in their life.
Transvestism is a form of fetishism (the clothing is the fetish), which is a type of paraphilia in its most extreme forms. In
transvestism (cross-dressing), men prefer to wear women’s clothing, or, far less commonly, women prefer to wear
men's clothing. This may be because women have a broader range of clothing considered consistent with gender.
However, they do not have an inner sense of belonging to the opposite sex or wish to change their sex, as do some
people with severe gender dysphoria. However, men who cross-dress may have feelings of gender dysphoria when
they are under stress or experience a loss.
Diagnosis of Transvestic Disorder
Doctors diagnose transvestic disorder when
People have been repeatedly and intensely aroused by cross-dressing, and the arousal has been expressed in fantasies,
intense urges, or behaviors.
with friends).
Most cross-dressers do not have transvestic disorder.
In making the diagnosis of transvestic disorder, the doctor specifies whether a person has a fetish or autogynephilia (a
man's arousal by thoughts or images of himself as a woman).
Treatment of Transvestic Disorder

Social and support groups
Sometimes psychotherapy
Only a few people with transvestic disorder seek medical care. Those who do may be motivated by an unhappy spouse or
by worry about how the cross-dressing is affecting their social life and work. Or they may be referred by courts for
The term cross-dressers is usually used to refer to people with transvestism. Transvestite is a less acceptable term and is
considered offensive. Cross-dressing in and of itself is not considered a mental health disorder. Cross-dressing
occurs in both heterosexual and homosexual men, and much more uncommonly in women. Nonbinary people who
dress in clothing typically associated with a different birth sex are generally not engaging in "cross-dressing" for the
purposes of sexual arousal.
Heterosexual males who dress in women’s clothing typically begin such behavior in late childhood. This behavior is
associated, at least initially, with intense sexual arousal.
Cross-dressers may, however, cross-dress for reasons other than sexual stimulation—for example, to reduce anxiety, to
relax, or, in the case of male cross-dressers, to experiment with the feminine side of their otherwise male
personalities.
Later in life (sometimes in their 50s or 60s), some men who were cross-dressers only in their teens and twenties develop
gender dysphoria. They may seek to change their body through hormones and genital (gender-affirming) surgery.
When a partner is cooperative, cross-dressing may not hurt a couple’s sexual relationship. In such cases, cross-dressing
men may engage in sexual activity in partial or full feminine attire with the consent of their partner.
When a partner is not cooperative, cross-dressers may feel anxious, depressed, guilty, and ashamed about their desire to
cross-dress. In response to these feelings, these men often purge their wardrobe of female clothing. This purging may
be followed by additional cycles of accumulating female clothes, wigs, and makeup, with more feelings of guilt and
Gender dysphoria
Gender dysphoria involves experiencing discomfort with one’s designated sex, such as feeling uncomfortable with their
physical body (which intensifies during puberty) to feeling uncomfortable with the expected social roles associated
with their designated sex.1 These feelings typically begin before or during adolescence.
What Is Gender Dysphoria?
Gender dysphoria refers to the persistent emotional and psychological distress a person experiences due to a mismatch
between their gender identity and designated sex at birth. 2,3 For example, a person whose designated sex at birth is
male may come to realize they emotionally, physically, and psychologically feel and identify as female.
Gender dysphoria is not considered pathological or a mental disorder; rather, it defines an area of vulnerability leading to
the development of social and psychological challenges.
Gender dysphoria
Terminology Related to Sex & Gender
There are several important terms associated with gender dysphoria. Gender identity development is an expected and
natural part of the human lifespan. In order to support those who experience gender dysphoria, one must be able to
understand and acknowledge the difference between gender as a social construct—or how society has developed
beliefs, norms, and expectations based on a gender binary of male and female—and the biological aspects of sex.
Here are some important terms to know about sex and gender:
Biological sex is also known as sex assigned at birth or designated sex at birth, which refers to the external
characteristics of a newborn, like genitalia and/or secondary sex characteristics, utilized by healthcare providers to
declare a newborn as male, female, or intersex.
Gender refers to a person’s innermost concept of self as male, female, a combination of both, or neither. 4
Gender identity involves a complex makeup of biological, environmental, and cultural factors reflecting a person’s
internal sense of oneself—in other words, how they perceive themselves and what they call themselves. 5 This
identity can be the same or different from their gender assigned at birth and is also known as a person’s expressed
and/or experienced gender.
Gender dysphoria
Transgender is considered an umbrella term that comprises all individuals whose gender identity does not conform to
expectations based on their gender assigned at birth. 6
Cisgender refers to a person whose gender identity aligns with those typically associated with their gender assigned at
birth. Gender identity was previously understood as a binary—male or female; however, in recent years gender has
come to be understood as a spectrum of identities from male and female, to a combination of both, or neither.
Gender fluid is a gender identity that isn’t limited to one specific gender but can shift over time. Gender fluid folks often
feel like they don’t fit exclusively within the conventional categories of male/female and that their gender identity
isn’t “fixed.”7
Nonbinary involves not identifying with a cisgender expression. This umbrella term can vary from person to person and
encompasses a wide range of gender identities beyond the binary, such as queer, gender fluid, bigender, etc. Some
common pronouns used by nonbinary people include they/them, ze/hir or ey/em, depending on their preferences. 7
Gender diverse: This all-inclusive term refers to people whose gender identity and expression don’t conform to
stereotypical societal expectations or the binary perception of gender (male/female) and may include anyone who
identifies as gender fluid, non-binary, queer, bigender, and more. 7
Sexual orientation refers to a person’s inherent or enduring emotional, romantic, and/or sexual attraction to other people
(e.g., lesbian, gay, bisexual, straight, queer, etc.). 4 There are many types of sexuality and gender identities, making it
important for people to not assume based on outward appearances or stereotypes.
Gender dysphoria
Types of Gender Dysphoria
Types of gender dysphoria include: 7,8
Body dysphoria: This often may be characterized by having a distorted view of one’s physical appearance. This can
refer to feeling a strong dislike for, and spending a great deal of time worrying about, their bodily appearance.
Social dysphoria: This relates to feelings of distress or uneasiness that people may experience in social situations when
their gender identity is not acknowledged by others, like using the wrong pronouns, wrongly assuming someone’s
gender, and so on.
Mind dysphoria: Typically seen in older adults, it emerges when they have feelings that are associated with their
assigned sex or one to which they can’t no longer relate.
Signs of Gender Dysphoria: What It Looks Like
Gender dysphoria can appear in several different ways for children, youth, and adults. Overall, the main attribute of
dysphoria occurs when one experiences consistent and persistent distress in the mismatch of their gender identity
and their designated sex at birth.
Gender dysphoria
Signs of Gender Dysphoria in Children
Throughout childhood, it is common for children to display periods of nonconforming gender expression in their play,
such as taking an interest and playing dress up in the clothes associated with the opposite sex. This play typically
does not persist into their grade school or adolescent years and reflects a naturally occurring phenomenon in human
development.6 These children are considered to be gender expansive, gender variant, or gender nonconforming.
However, some children, at very young ages, begin to recognize their gender is different from the sex they were assigned
at birth.6 This discovery can occur anywhere between the age of 2-4 years and is conveyed through their identity,
expression, or both.9 Early-onset gender dysphoria occurs when a child, in their preschool or elementary school
years, presents with persistent and consistent distress regarding their sex assigned at birth and the gender they
believe themselves to be.10
Examples of this can be seen in correcting parents when incorrect pronouns or gender labels are used as well as in an
increase in externalizing (e.g., angry outbursts, meltdowns, aggressive behavior) or internalizing (e.g., social
withdrawal, somatic complaints, feelings of nervousness or unloved) behaviors when referred to by the wrong
gender.
Gender dysphoria
Signs of Gender Dysphoria in Adolescents & Youth
The rate of adolescents referred to mental health services for gender identity concerns has rapidly increased over the past
two decades.11 Adolescence is an integral time for gender and sexual identity development, particularly for youth
who experience gender identity concerns.
Gender identity typically develops earlier than sexual orientation, with identities becoming more resolved during
adolescence.9 As previously stated, early-onset gender dysphoria may be more readily recognized by parents who
support their child with gender identity concerns. On the other hand, late-onset gender dysphoria may come as a total
surprise for the youth and their parents, and both may not necessarily be aware of it.
Teens with gender dysphoria are different from teens who are gender nonconforming, or those who behave and express
their gender in ways that don’t align with their gender assigned at birth. Teens with gender dysphoria experience
persistent distress in the mismatch of their gender identity with their designated sex at birth. They will have a deep
desire to be seen and treated as their gender identity.
Gender dysphoria
It is always necessary to take suicidal thoughts and behaviors seriously, and they should never be ignored or minimized.
Adolescents with gender dysphoria are particularly at risk for suicide, making it paramount for parents to engage in
conversations with their teens about their gender identity and finding ways to support them. 2
If gender dysphoria is not adequately addressed in childhood, as adolescents transition into their young adulthood, they
may experience increased emotional and psychological distress as well as poorer quality of life outcomes.
Sign of Gender Dysphoria in Adults

As of 2016, it was estimated there are 1.4 million transgender adults living in the United States, or 0.6% of the
population.14 Unresolved gender dysphoria can result in poor quality of life for transgender people, beginning in
childhood and lasting throughout their adolescence and adulthood.
The study revealed that most gender dysphoria is established by age 7. The average age of transgender individuals’
earliest memories and experience of gender dysphoria occurred early on, with transgender women’s earliest memory
and first experience of gender dysphoria at 4.5 and 6.7 years, respectively, and transgender men’s at 4.7 and 6.2
years, respective
Gender dysphoria
Teens who experience gender dysphoria are more inclined to hide their gender identity concerns in fear of rejection,
ridicule, or disapproval, not only from their peers but especially their parents. 18 This makes it even more important
for parents to know the significance of gender dysphoria and what it looks like.
Signs of gender dysphoria in adolescents include but are not limited to:
Persistent and consistent expressed desire they were born the wrong gender
Expressed desire that others treat them and refer to them as their gender identity
Changing their outward appearance to pass as their gender identity (e.g., dressing, grooming, presenting)
Feelings of disgust with their genitals to avoiding activities that would require them to touch or see their genitals (i.e.,
showering, having sex)
Distress and internal conflict causing impairment in one or more significant areas of life: Schooling, occupational, and
social functioning
Gender Dysphoria & Mental Health Concerns in Teens
Late-onset gender dysphoria may be preceded by or coupled with other adjustment and/or mental health concerns such as
school aversion, low self-esteem, anxiety, depressed mood, body image and eating disorders, non-suicidal self-harm
(e.g., hitting, cutting, burning), and suicidal thoughts and behaviors.13
Gender dysphoria
Gender Dysphoria Symptoms
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes one overarching diagnosis of gender
dysphoria with separate specific criteria for children, adolescents, and adults. 17 The diagnosis of gender dysphoria
hinges on the marked difference between one’s expressed and/or experienced gender and their sex assigned at birth.
This distress must also create problems or significant stress in other areas of a person’s functioning, including
relationships, school/occupation, and social life.
A mental health counselor, helping professional, and other allied healthcare providers will follow the World Professional
Association for Transgender Health Standards of Care (WPATH SOC) to diagnose and treat people with gender
dysphoria.18
In order for an adolescent or adult to be diagnosed with gender dysphoria, they must meet at least two of the following
criteria lasting over the past six months: 18
A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
A strong desire to be rid of one’s primary and/or secondary sex characteristics
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be of the other gender
A strong desire to be treated as the other gender
A strong conviction that one has the typical feelings and reactions of the other gender
Gender dysphoria
Gender Dysphoria Symptoms in Children
In children, gender dysphoria diagnosis requires at least six of the following criteria and an associated significant distress
or impairment in function, lasting at least six months: 18
A strong desire to be of the other gender or an insistence that one is the other gender
A strong preference for wearing clothes typical of the opposite gender
A strong preference for cross-gender roles in make-believe play or fantasy play
A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
A strong preference for playmates of the other gender
A strong rejection of toys, games and activities typical of one’s assigned gender
A strong dislike of one’s sexual anatomy
A strong desire for the physical sex characteristics that match one’s experienced gender
How Common Is Gender Dysphoria?
The overall population of transgender individuals in the United States is not fully understood, largely in part to previous
US Census data excluding gender identity. One study estimated that there are approximately one million transgender
adults living in the US, with this estimate indicative of younger adults representing more than 50% of the
participants in their study.19 Another study found that approximately 1.4 million adults, or 0.6% of the population, is
comprised of transgender individuals. 14
Gender dysphoria
What Causes Gender Dysphoria?
The exact causes of gender dysphoria are not entirely known. However, some experts hypothesize that biological
elements such as hormones in the womb, genes, and cultural and environmental factors may be implicated. Simply
put, gender dysphoria develops when a person experiences an intense discomfort or distress because their gender
identity doesn’t align with their sex assigned at birth or sex-related physical characteristics. 8
Treatment of Gender Dysphoria
People who experience gender dysphoria can seek care from their primary care providers, endocrinologists, and/or
mental health providers. Transitioning is at times at the forefront of treatment, whereas other mental health concerns
may take precedent, like if they are experiencing depression or suicidal ideation.
The Counseling Process for Gender Dysphoria & Transitioning
Overall, the purpose of counseling is to increase the quality of life for people who experience gender dysphoria and
identify as transgender. Mental health providers will help trans individuals and their loved ones understand the
emotional and physical impact of gender dysphoria, as well as explore the decision and resources to transition. 12
Gender dysphoria
Mental health providers will utilize different counseling approaches to support the individual’s unique needs, including:
Person-centered therapy
Cognitive behavioral therapy
Mindfulness-based stress reduction
Trauma-informed therapy
Solution-focused therapy
Dialectical behavioral therapy
Family systems therapy
The main aspects to transitioning and gender dysphoria management in counseling will cover:
Social Aspects
In addition to gender identity, trans people have several other social identities, including but not limited to age,
race/ethnicity, sexual orientation, socioeconomic status, emotional, physical, and social ability, spirituality,
educational level, and immigration status. The purpose of social transition is to assist the individual in integrating
these identities and live authentically.
Gender dysphoria
Relational Aspects
Mental health providers will support trans clients and their loved ones in understanding gender dysphoria and the
associated emotions and reactions to the transition process as well as coming to terms with the individual’s gender
identity.20 It is common for parents/caregivers, family members, and peers to experience a wide range of emotions
and may go through a grief process when they first learn about their child coming out as transgender or LGBTQ+.
Legal Aspects
A person may decide to legally transition as part of their gender-affirming care. Mental health providers will support the
individual in obtaining necessary legal documents to change their name and gender marker (i.e., change the gender
on their identification, passport, and/or birth certificate).
Educational & Vocational Aspects
Several challenges exist for trans people in their educational and workplace settings. Mental health providers will explore
client’s goals, concerns, and feelings regarding their educational and vocational pursuits.
Medical Aspects
As previously mentioned, medical transition may not be a primary objective for clients who are seeking care for gender
dysphoria.8,9 With that being said, mental health providers working with trans individuals and their loved ones may
assist those who are seeking guidance on medical transition.
Gender dysphoria
Hormone Therapy
Transgender people may pursue hormone therapy to suppress their endogenous hormones and develop secondary sex
characteristics different from those associated with their designated sex at birth. People assigned female at birth may
be prescribed testosterone to advance toward a more masculine or non-binary presentation, and people assigned male
at birth may be prescribed estrogen and testosterone-blocking hormones to advance toward a more feminine or non-
binary presentation.
Research has shown that, in addition to the positive physical effects of masculinizing and feminizing hormone therapy
for trans people, there is also a significant increase in emotional well-being. 7,8
Gender-Affirming Surgery
Mental health providers working with clients pursuing gender-affirming surgeries will support the client in familiarizing
themselves with their options, as well as the financial demands and recovery process from surgery. Trans individuals
who desire gender-affirming surgical interventions may elect for some surgeries over others. These interventions
differ based on the needs and desires of that individual. 8,18
Surgical interventions for trans feminine individuals include facial feminization surgeries, vocal cord surgery, chest
reconstructive surgery, and genital reconstructive surgeries – such as orchiectomy and vaginoplasty. Surgical
interventions for trans masculine individuals include chest reconstructive surgeries, hysterectomy and
oophorectomy, and genital reconstructive surgeries such as metoidioplasty and phalloplasty
Table of contents
01 02 03
About Reproductive
sexual health education Sexual orientation
You can describe the topic of You can describe the topic of You can describe the topic of
the section here the section here the section here
04 05 06
Reproductive Human Sexual
anatomy reproduction health services
You can describe the topic of You can describe the topic of You can describe the topic of
the section here the section here the section here
Whoa!
This can be the part of the presentation where you
introduce yourself, write your email…
01
About
sexual health
You can enter a subtitle here if you need it
Sexual and reproductive health
Mercury is the closest planet to the Sun Mercury takes a little more than 58 days
and the smallest one in the entire Solar to complete its rotation, so try to imagine
System. Contrary to popular belief, this how long days must be there! Since the
planet's name has nothing to do with the temperatures are so extreme, albeit not as
liquid metal. Mercury was, instead, named extreme as on Venus, Mercury has been
after the famous Roman messenger god deemed to be non-habitable for humans
Mercurius
Reproductive anatomy
Do you know what helps you make your point crystal clear? Lists
like this one:
● They’re simple
● You can organize your ideas clearly
● You’ll never forget to buy milk!
And the most important thing: the audience won’t miss the point of
your presentation
Human reproduction
Female Male
reproductive system reproductive system
Mercury is the closest planet to the Venus has a beautiful
Sun and the smallest one in the Solar name and is the second planet from
System—it’s only a bit larger than the Sun. It’s hot and has a poisonous
the Moon atmosphere
Sexual health and relationships
Consent Protect Check

Mercury is the closest Venus has a beautiful name Despite being red, Mars is
planet to the Sun and the and is the second planet actually a cold place. It’s
smallest of them all from the Sun full of iron oxide dust
Female reproductive system
Vagina Uterus
Mars is actually a very Venus has extremely
cold place high temperatures
Fallopian Ovaries
Jupiter is the biggest Saturn is a gas giant and
planet of them all has several rings
02
Reproductive
education
Male reproductive system
Penis Testicles Epididymis

Mercury is the closest Jupiter is the biggest Saturn is a gas giant and
planet to the Sun planet of them all has several rings
Vas deferens Sex glands

Venus has extremely Mars is actually a very
high temperatures cold place
About contraception
Injectables Vasectomy Patch

Mars is actually a very Venus has extremely Neptune is farthest
cold place high temperatures planet from the Sun
Male condom Sponge Spermicides

Mercury is the closest Saturn is a gas giant and Jupiter is the biggest
planet to the Sun has several rings planet of them all
Awesome
words
“This is a quote, words full of wisdom that
someone important said and can make the
reader get inspired”
—Someone Famous
A picture is worth a thousand words
98,300,000
Big numbers catch your audience’s attention
9h 55m 23s
Jupiter’s rotation period
333,000
The Sun’s mass compared to Earth’s
386,000 km
Distance between Earth and the Moon
Sexual health survey result
25% 50% 75%
Mercury Venus Mars

Mercury is the closest Venus has a beautiful name Despite being red, Mars is
planet to the Sun and the and is the second planet actually a cold place. It’s
smallest of them all from the Sun full of iron oxide dust
Sexual health check-up
Mercury 30%
Mars is actually a very cold
place
Venus 55%
Venus has extremely high
temperatures
Jupiter 90%
Jupiter is the biggest planet
of them all
Computer mockup
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03
Sexual orientation
How much sex education matter?
Venus
Venus is the second planet
from the Sun
Mercury
Mercury is the closest
planet to the Sun
Mars
Despite being red, Mars is
a very cold place
Menstruation timeline
Venus is the second Mars is a very
planet from the Sun cold place
Venus Mars
Mercury Jupiter
Mercury is the closest Jupiter is the biggest
planet to Sun planet of them all
Sexual health infographics
Mars Venus
Mars is a red planet Venus is a hot planet
Mercury Jupiter
Mercury is very small Jupiter is a gas giant
Female reproductive system
Uterine fundus Embrio
Uterus Fallopian tube
Ovarian ligament Ovary
Endometrium
Fimbriae Perimetrium
Myometrium Cervix
Cervical canal Vagina

Statistics on sexual health
Team A Team B Team C Team D
Mercury 0.06 0.53 0.38 0.38
Mars 0.11 9.4 0.53 0.78
Saturn 95.2 1.16 9.4 1.16

Survey on sex education
Mercury
Mercury is quite a
small planet
Venus
Venus has very high
temperatures
Saturn
Saturn is a gas giant
with rings
Follow the link in the graph to modify its data and then paste the new one here. For more info, click here
Male reproductive system
Epididymis
Urethra Vas deferens
Penis head Seminal vesicle
Testicle Prostate
Erectile tissue Bulbourethral gland

Birth control options
Hormonal IUD Implant
Mercury is the closest Neptune is farthest planet
planet to Sun from the Sun
Pill Hormonal Patch

Despite being red, Mars is method Jupiter is the biggest
a very cold place planet of them all
Ring Shot
Saturn is a gas giant and Venus is the second planet
has several rings from the Sun
Our team
Sofia Hill Kaliyah Harris

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Sexual and gender

SEXUAL DYSFUNCTIONS SEXUAL DYSFUNCTION NOT CAUSED BY ORGANIC DISORDERS

Sexual desire/arousal disorder Lack or loss of sexual desire

Female sexual/arousal disorder Sexual aversion and lack of sexual enjoyment

Male hypoactive sexual desire disorder Failure of genital response

ORGASM DISORDERS ORGASMIC DYSFUNCTIONS

Female orgasmic disorder Premature ejaculation

Delayed ejaculation Non-organic dyspareunia

Premature ejaculation Non organic vaginisismus

PARAPHILIC DISORDER DISORDER OF SEXUAL PREFERENCE

Exhibitionist disorder Exhibitionism

Frotteuristic disorder Voyeurism

Sexual masochism disorder Sadomasochism

Sexual sadism disorder

PARAPHILIC DISORDER DISORDER OF SEXUAL PREFERENCE

Anomalous target preferences Paedophilia

Paedophilic disorder Fetishism

Fetishistic disorder Fetishistic transvestism

GENDER DYSPHORIA GENDER IDENTITY DISORDERS

Symptoms and Causes

Treatment of Exhibitionistic Disorder

Asphyxiophilia (autoerotic asphyxiation)

Treatment of Transvestic Disorder

Sign of Gender Dysphoria in Adults

Consent Protect Check

Penis Testicles Epididymis

Vas deferens Sex glands

Injectables Vasectomy Patch

Male condom Sponge Spermicides

25% 50% 75%

Mercury Venus Mars

Uterus Fallopian tube

Ovarian ligament Ovary

Cervical canal Vagina

Team A Team B Team C Team D

Mercury 0.06 0.53 0.38 0.38

Mars 0.11 9.4 0.53 0.78

Saturn 95.2 1.16 9.4 1.16

Urethra Vas deferens

Penis head Seminal vesicle

Erectile tissue Bulbourethral gland

Pill Hormonal Patch

Sofia Hill Kaliyah Harris

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