1. What is normal sexual behavior? (p. 308) This chapter discusses sexual dysfunctions, gender identity disorders, and paraphilias, as well as sexual coercion. The sexual and gender identity disorders are the hardest to distinguish from normal sexual behavior because of cultural differences as well as moral and legal judgments. Normal sexual behavior is poorly understood and differs depending upon the historical period and one's culture, although the Merck Manual of Diagnosis and Treatment indicates that behavior is a problem when it is persistent and recurrent over time, causes personal distress, and significantly affects usual relationships with your sexual partner. The question of compulsive sexual behavior became particularly salient with President Clinton's affair with Monica Lewinsky. Although it is not classified by DSM-IV-TR, sexual scientists use such terms as hypersexuality, erotomania, nymphomania, and satyriasis to refer to this phenomenon. The first reliable information concerning human sexuality came from the survey research work of Alfred Kinsey. Masters and Johnson used laboratory research to study physiological sexual responses. More recently, the Janus Report described sexual practices in the United States.
2. The sexual response cycle (p. 310) The sexual response cycle has an appetitive (desire) phase, when fantasies about sex increase. The excitement phase occurs when direct sexual stimulation (not necessarily physical) increases blood flow to the genitals. The orgasm phase produces involuntary contractions and the release of sexual tension. Men ejaculate then have a refractory period where additional stimulation does not produce orgasm; women are capable of multiple orgasms. The body then returns to relaxation during the resolution phase. Decreased functioning in any of these phases can be criteria for a sexual dysfunction.
3. Homosexuality, aging, and sexual activity (p. 312) Homosexuality is not a mental disorder. There are no physiological differences in sexual arousal, no differences in psychological disturbance, no gender identity distortions that differentiate homosexuals and heterosexuals.
4. Aging and sexual activity (p. 315) Sexuality continues into old age, although physiological changes can lead to changes in sexual activity. Patterns of sexuality during middle age are maintained. The Janus survey suggests that sexual activity and enjoyment remain high among those 65 and older.
5. Sexual dysfunctions (p. 317) Psychosexual dysfunction disorders involve any persistent disruption in the normal sexual response cycle. DSM-IV-TR requires that factors such as frequency, chronicity, distress, and impact on functioning be considered in the diagnosis. Sexual desire disorders involve a lack of interest in or aversion to sex. These are more common in women than in men, and there are many questions about what normal sexual interest is (about 20 percent of the adult population is believed to suffer from this disorder).
   Sexual arousal disorders are problems occurring during the excitement phase of the sexual response cycle. Erectile disorder is the mans inability to maintain an erection sufficient for intercourse. Physical conditions may account for a large minority of cases. Distinguishing biogenic erectile dysfunction from psychogenic cases is difficult. Primary dysfunction is when a man has never been successful in intercourse; secondary dysfunction means the problem is situational.
   Female sexual arousal disorder involves lack of vaginal lubrication or erection of the nipples. This disorder, too, can be primary or secondary.
   Orgasmic disorders involve the inability to achieve orgasm after receiving adequate stimulation in the excitement phase. Female orgasmic disorder means a woman is unable to achieve orgasm. Many questions arise about whether the lack of an orgasm is a normal variant of sexual behavior or a disorder. This sexual dysfunction can be primary (no orgasm ever experienced) or secondary (situational problems). Some argue the disorder should not be diagnosed until all experiences conducive to orgasm have proven ineffective. Male orgasmic disorder, the inability to ejaculate intravaginally, is relatively rare and little is known about it. Premature ejaculation is a common disorder involving an inability to delay ejaculation during intercourse, but definitions of premature vary. Sexual pain disorders include dyspareunia (persistent pain in the genitals before, during, or after intercourse) and vaginismus (involuntary muscular contraction of the outer vagina). DSM-IV-TR also notes sexual dysfunction owing to a general medical condition and substance-induced sexual dysfunction.
6. Etiology and treatment of sexual dysfunctions (p. 324) Many dysfunctions are due to a combination of biological and psychological factors. Organic factors include sex hormone levels (although this is not well understood), blood flow in the genitals, hypersensitivity to physical stimulation, vascular diseases, and the side effects of medications. Medical treatments include exercise, oral medication (Viagra), surgery, and injections into the penis of substances that induce erection. Psychological factors include predisposing causes, such as early experiences and upbringing, and current concerns, such as poor marital relations and performance anxiety. Research shows that anxiety and self-focus impair performance.
   Treatment often includes education, anxiety reduction, structured behavioral exercises, and improved communication. Specific treatments for dysfunctions include masturbation as treatment for female orgasmic disorder, the squeeze technique for premature ejaculation, and relaxation and insertion of dilators for vaginismus. The glowing reports of success for these methods have been called into question recently. Long-term success requires relapse prevention.
7. Gender identity disorders (p. 328) Gender identity disorders, often called transsexualism, involve a conflict between anatomical sex and gender self-identification. A second disorder is called gender identity disorder not otherwise specified. Transsexuals, have a lifelong conviction that they are in the body of the wrong sex. Sex role conflicts start at an early age; they are more common in boys than in girls. Prevalence estimates range from 1 in 100,000 to 1 in 37,000 among males and about one-quarter that rate among females. The not-otherwise-specified disorder may involve preoccupation with castration without desire to acquire the characteristics of the other sex, stress-related cross-dressing, or persistent cross-dressing without the other criteria of gender identity disorder.
   Because it is rare, we do not know much about the disorders cause. Some animal research supports the biological view that neurohormones explain gender identity disorders. However, children have adopted the gender identity that their parents imposed rather than that of their genetic makeup. Psychoanalysts suggest that sexual deviations symbolize unconscious conflicts involving separation from the mother. Behaviorists note that parental encouragement to act like the opposite sex and cross-dress may lead to gender identity disorder.
   Most treatment programs with children having gender identity disorder assign boys to male therapists, to facilitate identification with a male, and teach behavior modification skills to the parents. Sex conversion treatment involving hormones and surgery can alter the apparent sex of transsexuals; woman-to-man changes seem to have more positive outcomes. It is particularly positive for those who are highly motivated and carefully screened, who have stable work records and good social support, although many transsexuals remain depressed and suicidal after surgery. Behavior therapy, including aversive conditioning, reinforcing heterosexual fantasies has been used. Controversy exists whether sex-conversion surgery or psychotherapy should be advanced in treating individuals with gender identity disorders.
8. Paraphilias involving nonhuman objects (p. 333) Paraphilias are sexual disorders lasting at least six months in which repeated intense sexual urges exist for nonhuman objects, real or simulated suffering, or nonconsenting others. Either the urge is acted upon or causes severe distress. Sex offenders often have multiple paraphilias. They are overwhelmingly male problems.
   Fetishism is a strong sexual attraction to inanimate objects, such as shoes or underwear. As a group, fetishists are not dangerous. In transvestic fetishism, the person obtains sexual arousal by dressing in the clothes of the opposite sex. Most transvestites are heterosexual males who use cross-dressing to facilitate sexual intercourse, but many transvestites feel they have both male and female personalities.
9. Paraphilias involving nonconsenting persons (p. 336) Exhibitionism involves urges, acts, or fantasies about exposing one's genitals to strangers. Women commonly report being victims. Most exhibitionists are young married men who want no further contact with the women to whom they expose themselves. Most have fantasies of being admired by female observers. Voyeurism is sexual gratification obtained primarily from observing others genitals or others engaged in sex. Acts are repetitive and premeditated. Frotteurism involves intense sexual urges to touch and rub against nonconsenting individuals. Pedophilia is characterized by adults obtaining erotic gratification from sexual fantasies about or involving sexual contact with children. DSM-IV-TR criteria include being at least 16 years old and five or more years older than the victim. The disorder is not rare; 20 to 30 percent of women report having had a childhood sexual encounter with an adult man. Victims often have long-term psychological difficulties. Molesters tend to be impulsive, passive, and alcoholic. Social skill deficits and below-average intelligence are also reported. More than half of one sample used hard core pornography to excite themselves into committing an offense.
10. Paraphilias involving pain or humiliation (p. 338) Sadism and masochism involve associations between pain or humiliation and sex. Sadists inflict pain; masochists receive it. Often people engage in both roles. Some cases develop from early experiences with pain, but causal explanations are currently weak.
11. Etiology and treatment of paraphilias (p. 339) Some research findings suggest biological causes for paraphilias but replication is needed. Psychodynamic theory links paraphilias to unresolved oedipal conflicts, particularly castration anxiety. Treatment involves making these unconscious conflicts conscious. Behavioral theory stresses early conditioning experiences, masturbation fantasies, and a lack of social skills. Conditioning must overcome preparednessthe fact that some stimuli become associated more readily than others because of evolutionary pressures. Treatment seeks to extinguish inappropriate behaviors and reinforce appropriate ones. One example is aversive behavior rehearsal, in which the exhibitionist exposes himself to a prepared female audience and must explain his fantasies. Results of behavioral treatments are positive but largely based on single-subject reports.
12. Sexual aggression (p. 341) Sexual coercion refers to all forms of sexual pressure. Sexual aggression is restricted to sexual actions that are performed against a persons will by way of force, argument, pressure, authority, or drugs.
    Rape is defined in the text as forced intercourse accomplished through force or threat of force; statutory rape is sexual intercourse with someone under a certain age (depending on the particular state). Rape can be seen as either a sexual act, a violent act, or both. It is common: An estimated one-fifth of all U.S. women will be raped in their lifetime. Many rapists are friends or acquaintances of the victims. Many young men who do not rape try to coerce women into intercourse. Both rapists and their victims tend to be young. Victims may experience prolonged distress and sexual dysfunction. Consistent with posttraumatic stress disorder, survivors may experience rape trauma syndrome. It consists of an acute phase involving fear, self-blame, depression, and a long-term phase that slowly leads to reorganization. Flashbacks during sex are common. Rapists are most often motivated by power and anger, not by sex; 5 percent are rapists who enjoy inflicting pain on their victims. Nonrapists report being aroused by aggressive sex; a significant proportion of university men report some likelihood they would rape if they could get away with it. Where there is general acceptance of violence, there is a spillover effect on rape. The cause of rape can be seen as sociocultural (male sex roles and general social violence) or sociobiological (innate sex differences in sexual motivation).
    Incest is sexual relations between close relatives. Most common is father-daughter incest. Estimates of incidence rates range from 48,000 to 250,000 cases per year. Incestuous fathers are more likely than nonincestuous fathers to have been victims of childhood sexual abuse, although this is not common. Survivors have a range of difficulties, continuing into adulthood.
    Treatment for incest offenders and rapists traditionally involves imprisonment, although punishment is more common than therapy. Behavioral therapy, surgical castration, and drug therapies have all been used. Results are mixed, with more success treating child molesters and exhibitionists than rapists. Biological treatments, such as surgical castration, in particular, have been very controversial.