This section consists of two subsections. The first focuses on the treatment of sexual dysfunctions such as hypoactive sexual desire, premature ejaculation, male erectile disorder, dyspareunia, and female arousal and orgasmic disorders. The second focuses on the treatment of transvestism, gender identity disorders (Gender Identity Disorder of Adulthood, Females With Gender Identity Disorder, Gender Identity Disorder in Children and Adolescents), and the paraphilias.

The chapters on sexual dysfunction emphasize that sexual function is the end product of complicated, interactive biological and psychological influences. Psychological influences on sexual behavior include the individual life experiences of each partner, the partners’ common experience as a couple, and their current interactional pattern. Thus, sexual dysfunction can have its etiology in a myriad of biological and psychological systems. Effective intervention involves an appreciation of the complexity of the influences that establish and maintain sexual symptoms.

The treatment of sexual dysfunction has evolved considerably during the late 1990s as a result of the introduction of effective biological therapies. With an array of biological and psychological therapies for sexual disorders, clinicians have more reason to take a psychobiological approach to sexual problems. Many of the chapters in this section reflect the current biopsychosocial approach to evaluation and treatment.

Sexual Desire Disorders, by Alan Riley and Kathyrn May of the University of Central Lancashire of the United Kingdom, captures the complexity of evaluating and treating sexual desire disorders. This chapter illustrates why hypoactive sexual desire disorders are often refractory to treatment. The authors critically review the evidence for psychological interventions as well as endocrinological approaches to the treatment of male and female hypoactive sexual desire disorders. A brief section on the treatment of hyperactive sexual desire concludes the chapter. The section continues with chapters by Richard Balon on the treatment of male erectile disorder and by Adam Keller Ashton, Carolyn Young, and Joseph LoPiccolo on premature ejaculation. The two chapters comprehensively address both psychological and pharmacological approaches to treatment, reflecting the full armamentarium available to the modern clinician. In “Female Sexual Dysfunction” Chapter, Marita McCabe of Deakin University in Australia surveys empirical data concerning the treatment of female sexual arousal and orgasmic disorders and outlines the components of an integrated treatment approach. Finally, Sandra Risa Leiblum, in “Sexual Pain Disorders” Chapter, provides an outstanding review of the treatment of dyspareunia and vaginismus, emphasizing the need to consider both physical and psychological etiologies.

Treatment of the pathologies of sexual identity occupies five chapters (Sexual Desire Disorders; Male Erectile Disorder; Female Sexual Arousal Disorder and Female Orgasmic Disorder; Premature Ejaculation and Male Orgasmic Disorder; Sexual Pain Disorders). Each author in these chapters properly discusses the uncertainty that exists regarding where the conventional or normal blends into the pathological. The nosology of sexual identity disorders is evolving. This evolution is partially spurred on by technological changes in our culture. Now that the Internet is a new fact of life, men and women have new means of sexual arousal and orgasmic gratification. Behavior patterns that older mental health professionals never witnessed are appearing - for instance, addiction to Internet chat rooms. Grassroots self-help organizations have demonstrated that gender identity variations and sexual addictions exist that have yet to be addressed in DSM-IV (American Psychiatric Association 1994). In addition, political voices are urging the removal of the diagnostic categories of gender identity disorder and paraphilia from the DSM, just as homosexual and bisexual orientations were deleted as diagnoses in 1974. These evolutionary pressures notwithstanding, mental health professionals are often called upon to evaluate and treat individuals whose sexual identities are atypical. Although their stated reasons for seeking help may be no different from those of people with conventional sexuality, individuals with atypical sexual identity also present because of problems directly related to their gender identity or gender role behavior or unusual or criminal sexual behaviors.

Sexual identity consists of at least three separate components: 1) gender identity, the sense of self as male and female and masculine and feminine; 2) orientation, the predispositions to love and have sex with a person of one or another birth sex; 3) intention, what one desires to do to a partner or have done to one?s body during sexual behavior. Variations in gender identity and intention are the only components that are diagnosed as mental illnesses. Patients with gender identity disorders have persistent fantasies, wishes, identifications, and behaviors of the opposite sex. To a conspicuous degree, males want to be females and females want to be males. Although DSM-IV provides only one diagnosis - gender identity disorder - for these conditions, it directs clinicians to subdivide that diagnosis by age - that is, gender identity disorder of childhood, of adolescence, or of adulthood. A few individuals are diagnosed with gender identity disorder not otherwise specified. The most prevalent unconventionality of gender identity in the general population of males is transvestism. Kenneth Zucker, in his chapter on gender identity disorder of childhood and adolescence, and George Brown, in his chapter on transvestism and gender identity disorder of adulthood, have provided excellent accounts of the treatment of these conditions.

Unconventionality of orientation - homosexuality - is not a psychiatric diagnosis. The reader will find no discussion of it in this book devoted to psychiatric treatment. It is apparent, nonetheless, that the process of coming to recognize and accept to various degrees one’s identity as a gay or lesbian person can be painful and difficult, with personal, interpersonal, and intrafamilial conflicts and dilemmas often generating symptoms of psychological distress.

The paraphilias represent the pathology of the intention component. The conventional forms of intention involve cooperating with another person to give and receive sexual pleasure, often culminating in genital stimulation and union. The paraphilias are a diverse group of almost 50 patterns of arousal involving children, age-inappropriate partners, inanimate objects, pain, power, humiliation, suffering, unusual activities, and nonpersonal contact. While no single chapter could do justice to the breadth of paraphilic manifestations and their compassionate treatment, Martin Kafka ably presents the general approaches to paraphilia. In Chapter 68, he introduces the reader to an emerging arena of psychopathology known as paraphilia-related disorder or sexual addiction. These patterns seem paraphilic in their consequences and comorbidities but in fact represent a compulsive drivenness to conventional sexual behavior.

In “Pedophilia” Chapter, Gene Abel, Candice Osborne, and Alexandra Phipps thoughtfully illustrate the elements of treatment of pedophilia. Pedophilia has been singled out for a separate chapter because of its vital public health ramifications - an alarming percentage of boys and girls are sexually abused by teenagers and adults. It is important for all clinicians to realize that many of the children who are sexually victimized by older persons are not victimized by people who meet DSM-IV criteria for pedophilia. Pedophilia has one criteria-based meaning to mental health professionals and another, looser, meaning to the criminal justice system and the world at large. Many men and women who take advantage of children sexually do not have an exclusive interest in children. The authors remind us both of the large scope of this problem and of the fact that our conceptions of who is and who is not a pedophile are far from complete.

Society has a large stake in issues involving abnormal gender identity and intention. Mental health clinicians are citizens of this society and typically initially react to these topics with private moral outrage, personal derision, negative countertransference, and prejudice. In dealing with these men and women, physicians have an opportunity to learn about sexual development that fails to proceed along expected lines. These conditions do not appear de novo in adulthood. Often, they have been present since before puberty, although the physiology of gonadarche typically causes the condition to be experienced with particular intensity during adolescence. In the process of working with these patients, clinicians have the opportunity to transcend ordinary social attitudes and to learn much more about the processes of sexual development, its adolescent and adult evolution, and themselves.

Reference
_{American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994}

By R. Taylor Segraves, M.D., Ph.D.
Stephen B. Levine, M.D.