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I. SEXUAL DYSFUNCTIONS:
A. DESIRE PHASE DISORDERS:
1. HYPOACTIVE SEXUAL DESIRE DISORDER:
A. Persistently or recurrently deficient (or absent) sexual
fantasies and desire for sexual activity. The judgment of
deficiency or absence is made by the clinician, taking into
account factors that affect sexual functioning, such as age and
the context of the person's life.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The sexual dysfunction is not better accounted for by
another Axis I disorder (except another sexual dysfunction) and
is not due exclusively to the direct physiological effects of a
substance (eg, a drug of abuse, a medication) or a general
medical condition.
2. SEXUAL AVERSION DISORDER:
A. Persistent or recurrent extreme aversion to, and avoidance
of, all (or almost all) genital sexual contact with a sexual
partner.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The sexual dysfunction is not better accounted for by
another Axis I disorder (except another sexual dysfunction).
B. SEXUAL AROUSAL DISORDERS:
1. FEMALE SEXUAL AROUSAL DISORDER:
A. Persistent or recurrent inability to attain, or to
maintain until completion of the sexual activity, an adequate
lubrication-swelling response of sexual excitement.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The sexual dysfunction is not better accounted for by
another Axis I disorder (except another sexual dysfunction) and
is not due exclusively to the direct physiological effects of a
substance (eg, a drug of abuse, a medication) or a general
medical condition.
2. MALE ERECTILE DISORDER:
A. Persistent or recurrent inability to attain, or to
maintain until completion of the sexual activity, an adequate
erection.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The sexual dysfunction is not better accounted for by
another Axis I disorder (except another sexual dysfunction) and
is not due exclusively to the direct physiological effects of a
substance (eg, a drug of abuse, a medication) or a general
medical condition.
C. ORGASMIC DISORDERS:
1. FEMALE ORGASMIC DISORDER:
A. Persistent or recurrent delay in, or absence of, orgasm
following a normal sexual excitement phase. Women exhibit wide
variability in the type or intensity of stimulation that
triggers orgasm. The diagnosis of female orgasmic disorder
should be based on the clinician's judgment that the woman's
orgasmic capacity is less than would be reasonable for her age,
sexual experience, and the adequacy of sexual stimulation she
receives.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The orgasmic dysfunction is not better accounted for by
another Axis I disorder (except another sexual dysfunction) and
is not due exclusively to the direct physiological effects of a
substance (eg, a drug of abuse, a medication) or a general
medical condition.
2. MALE ORGASMIC DISORDER:
A. Persistent or recurrent delay in, or absence of, orgasm
following a normal sexual excitement phase during sexual
activity that the clinician, taking into account the person's
age, judges to be adequate in focus, intensity, and duration.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The orgasmic dysfunction is not better accounted for by
another Axis I disorder (except another sexual dysfunction) and
is not due exclusively to the direct physiological effects of a
substance (eg, a drug of abuse, a medication) or a general
medical condition.
3. PREMATURE EJACULATION:
A. Persistent or recurrent ejaculation with minimal sexual
stimulation before, on, or shortly after penetration and before
the person wishes it. The clinician must take into account
factors that affect duration of the excitement phase, such as
age, novelty of the sexual partner or situation, and recent
frequency of sexual activity.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The premature ejaculation is not due exclusively to the
direct effects of a substance (eg, withdrawal from opioids).
D. SEXUAL PAIN DISORDERS:
1.
DYSPAREUNIA:
A. Recurrent or persistent genital pain associated with
sexual intercourse in either a male or female.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The disturbance is not caused exclusively by vaginismus or
lack of lubrication, is not better accounted for by another Axis
I disorder (except another sexual dysfunction), and is not due
exclusively to the direct physiological effects of a substance
(eg, a drug of abuse, a medication) or a general medical
condition.
2. VAGINISMUS
A. Recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that interferes
with sexual intercourse.
B. The disturbance causes marked distress or interpersonal
difficulty.
C. The disturbance is not better accounted for by another
Axis I disorder (eg, somatization disorder) and is not due
exclusively to the direct physiological effects of a general
medical condition.
II. PARAPHILIAS
In general, less is known about the paraphilias than about
the sexual dysfunctions. Much of the information available is
relevant to the paraphilias in general. Comments about etiology,
the value of psychological testing, and so on are more likely to
be relevant to the broad category rather than to one specific
diagnosis. For that reason we initially review these disorders
as a broad category and then provide a brief discussion of
individual diagnoses.
Diagnostic Criteria
A. Recurrent, intense sexually arousing fantasies, sexual
urges, or behaviors-generally involving (1) nonhuman objects,
(2) the suffering or humiliation of oneself or one's partner, or
(3) children or other nonconsenting persons-that occur over a
period of at least 6 months (American Psychiatric Association
1994, pp. 522-523).
B. The diagnosis is not made unless the fantasies, sexual
urges, or behaviors cause clinically significant distress or
impairment in social, occupational, or other important areas of
function.
PARAPHILIC DIAGNOSES - The descriptions are based on DSM-IV
diagnostic criteria:
Exhibitionism
Exhibitionism involves recurrent, intense, sexually arousing
fantasies, sexual urges, or behaviors involving the exposure of
one's genitals to an unsuspecting stranger. The exhibitionist
may or may not masturbate coincidentally with the exposure of
his genitals. The victim's reaction, or the exhibitionist's
fantasy of that reaction, plays a major role in his sexual
satisfaction. Exhibitionistic behavior is often ritualized, with
the same behavioral patterns repeated during each episode.
Fetishism
Fetishism involves recurrent, intense, sexually arousing
fantasies, sexual urges, or behaviors involving nonliving
objects, often articles of women's clothing. These objects are
not limited to articles of women's clothing used in
cross-dressing or to devices designed for the purpose of sexual
stimulation.
The fetish object is frequently used for arousal during
masturbation, and sexual arousal may be impossible in the
absence of the object. If there is a sexual partner, the partner
may be asked to wear or in some way use the fetish object during
sexual activity.
Frotteurism
Frotteurism involves recurrent, intense, sexually arousing
fantasies, sexual urges, or behaviors involving touching and
rubbing against a nonconsenting person. This behavior frequently
occurs in crowded public places, which afford the perpetrator a
reasonable opportunity for escape.
Pedophilia
Pedophilia involves recurrent, intense, sexually arousing
fantasies, sexual urges, or behaviors involving sexual activity
with a prepubescent child or children (generally age 13 years or
younger). A person must be at least 16 years of age and at least
5 years older than the child or children affected for the
diagnosis to be made. Individuals in late adolescence involved
in an ongoing sexual relationship with a 12 or 13 year old are
excluded.
Individuals with this disorder tend to focus on children in a
specific age range. Some have exclusively heterosexual interests
(eg, focusing on girls age 8-11 years), others have exclusively
homosexual interests (eg, focusing on boys age 9-12 years),
whereas still others are attracted to either sex. The behavior
may range from looking, to fondling, masturbation, and various
degrees of penetration and coercion. Pedophiles may confine
their behavior to their own children, their extended family, or
strangers. Individuals with pedophilia often use elaborate
intellectual rationalization to justify their behavior and may
have well-developed and practiced manipulative techniques to
entice children into sexual interaction. In many cases, this is
an extremely chronic disorder with strong compulsive elements.
Some individuals who focus on strangers have molested hundreds
of children. This is one of the paraphilias that creates the
most intense social approbation and is likely to lead to
extensive entanglement in the legal system and incarceration.
Sexual Masochism
Sexual masochism involves recurrent, intense, sexually
arousing fantasies, sexual urges, or behaviors involving the act
(real, not simulated) of being humiliated, beaten, bound, or
otherwise made to suffer.
Pornography related to sadomasochistic themes is widely
available, but the implications of this availability for the
prevalence of such disorders in the population are unclear. Some
individuals confine their masochistic urges to fantasy, some act
on these urges alone accompanied by masturbation, and others
involve partners. Some prostitutes develop flourishing practices
serving the needs of men with this disorder for domination. Some
individuals need to escalate the intensity of their masochistic
behavior over time, which on occasion results in severe injury
or death.
Sexual Sadism
Sexual sadism involves recurrent, intense, sexually arousing
fantasies, sexual urges, or behaviors involving acts (real, not
simulated) in which the psychological or physical suffering
(including humiliation) of a victim is sexually exciting to the
person.
Some individuals with sexual sadism confine their sadism to
fantasy, others team up with a consenting partner (often with
sexual masochism), and still others inflict sexual pain on
unwilling victims. The latter individuals have a tendency to
continue to act out until apprehended and often escalate the
severity of their sadistic behavior until they may present a
true danger of death or serious injury to their victims.
Sadistic sexual fantasies often begin in childhood, and the
disorder has a chronic course.
Transvestic Fetishism
Transvestic fetishism involves recurrent, intense, sexually
arousing fantasies, sexual urges, or behaviors involving
cross-dressing. The diagnosis may be qualified by the specifier
with gender dysphoria, if the patient has persistent discomfort
with his assigned gender role.
In this disorder cross-dressing is done for purposes of
sexual arousal and is usually accompanied by masturbation. Men
with this disorder may take pleasure in wearing concealed
articles of female clothing throughout the day. Cross-dressing
behavior often takes on elements of increasing risk over time,
beginning with cross-dressing alone in the privacy of the home
and progressing to going out in public completely cross-dressed.
At times the risk of discovery seems to contribute to the
individual's sexual arousal.
This disorder is sometimes accompanied by gender dysphoria
but is not diagnosed if the cross-dressing occurs only in the
context of gender dysphoria without the element of sexual
arousal. There is an extensive transvestic subculture with
published magazines and a national organization of support
groups. Episodes of cross-dressing may be accompanied by varying
degrees of dissociation. The disorder tends to be chronic.
Transvestic fetishism is not necessarily associated with a
homosexual sexual object preference.
Voyeurism
Voyeurism involves recurrent, intense, sexually arousing
fantasies, sexual urges, or behaviors involving the act of
observing an unsuspecting person who is naked, in the process of
disrobing or engaging in sexual activity.
In general, for individuals with this disorder the act of
looking is the source of sexual arousal, and although it may be
fantasized, no sexual contact with the person observed is
sought. Occasionally, however, an individual may place himself
in a compromising position in order to observe and may contact
and even harm the victim in order to escape discovery. Although
it is clearly infrequent, there have been reports of chronic
voyeurism evolving into rape.
Paraphilia Not Otherwise
Specified
This category includes the numerous paraphilic foci that are
not included in the preceding categories.
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