Sexual & Gender Identity Disorders

Definiitons

 

Sex 

á   An objective biological variable

á   Types:  Male, female, intersex (hermaphrodite; ambiguous genitalia; fertility varies; .0005%)

 

Gender

á   A psychological variable

á    Subjective identification as male, female, transsexual (identity of the opposite sex)

 

Sexual & Gender Identity Disorders

Definitions conÕd

 

Sex defined by:

á   Anatomy

o External and internal reproductive organs

o Secondary characteristics after puberty

¤      e.g. pubic hair, voice, breasts

á   Sex chromosomes

 

Sexual & Gender Identity Disorders

Sex Chromosomes

 

 

á   XX female                     — XY Male

 

 

á   XO intersex*                 — XO/XY intersex*

 

á   XYY intersex*               — XXY intersex*

 

 

* fertility varies

Sexual & Gender Identity Disorders

DSM

 

3 Major Types Of Sexual And Gender Identity Disorders:

 

1. Gender Identity Disorder (GID)

i.e. transsexualism

 

2. Paraphilias

 

3. Sexual Dysfunctions

 

Sexual & Gender Identity Disorders

 

Gender Identity Disorder

á    Sense of self as a male or female is not congruent with anatomy and is distressful

Paraphilias

á   Sexual attraction to an unusual object or activity that causes distress or dysfunction

Sexual dysfunctions

á   Sexual performance or arousal difficulties

that cause distress or dysfunction

Sexual & Gender Identity Disorders

Gender Identity Disorder

 

á   A strong & persistent cross-gender identification

 

o  Not just a desire for a perceived cultural advantage of being the other sex

 

o  Not the result of an intersex condition
 i.e. hermaphrodite

 

á            Prevalence

o  0.00003% males

o  0.00001% females

Defining Abnormal Behavior

 

á   Statistical infrequency

 

á   Violation of norms

 

á   Unexpectedness

 

á   Personal distress*

 

á   Disability/dysfunction*

 

* GID not controversial but not considered a DX in all cultures or times in history—e.g. Etruscans

 

Gender Identity Disorder

 

 

Diagnostic criteria (differs by age):

 

A. Desire to be the opposite sex

 

B. Discomfort with his or her sex

 

- Feels an inappropriate sex role

 

 

Gender Identity Disorder

 

Desire to be the Opposite Sex

 

Children

á    Verbally insists to be the other sex

 

á   Cross-dressing (how define?)

 

á   Preference for cross-sex roles and stereotypical activities/play (how define?)

 

 

Gender Identity Disorder

 

Desire to be the Opposite Sex contÕd

 

Adolescents & Adults

 

á   Stated desire to be the other sex

 

á   Frequent passing as the other sex

 

á    Desire to live & be treated as the other sex

 

á    Conviction has feelings of the other sex

 

 

 

Gender Identity Disorder

 

Discomfort with Sex

 

Children: Boys

 

á   Feels penis/testes are disgusting

 

á   Feels penis/testes will disappear

 

á   Asserts preference to not have a penis/testes

 

á   Rejects stereotypical male toys, games, and activities (how define?)

 

 

Gender Identity Disorder

 

Discomfort with Sex contÕd

 

 

Children: Girls

 

á   Refusal to urinate in sitting position

 

á   Asserts she will grow a penis

 

á   Asserts she does not want breasts

 

á   Aversion toward feminine clothing

 

 

Gender Identity Disorder

 

 

Discomfort with Sex contÕd

 

Adolescents & adults

 

á    Belief born the wrong sex

 

á   Preoccupation with eliminating primary and secondary sex characteristics

 

o  e.g., hormones or surgery to alter genitalia

o  e.g., electrolysis

 

 

Gender Identity Disorder Etiology

 

Causes are:

 

á   Unknown

 

á   Not related to intersex

    

á   Both hormonal & learning?

 

o  Reinforcement and modeling?

 

 

Gender Identity Disorder Treatments

 

Cognitive Behavioral Treatment

á   Classical conditioning & cognitive restructuring

o  Rare case studies report success

 

Biologial and Cognitive Behavioral Treatment

á   Sex-reassignment surgery

á   Behavioral rehearsal

á   Cognitive restructuring of causal attributions

á   Problem-solving

o  High success rate for wide age range

 

Gender Identity Disorder – Treatments

 

Sex Reassignment Surgery and Cognitive Behavioral Treatment Outcome

 

Docter (1985)

á    74 year old male

 

 

Cohen-Kettenis & vanGoozen (1997)

á    22 adolescents 16-18 y/o

Sexual & Gender Identity Disorders

Paraphilias

 

á            Sexual attraction is to unusual objects or sexual activities

 

á            Not just fantasies, but behavior

 

á            Creates distress or dysfunction*

 

 

á            Some illegal (possible harm to others)*

 

 

 

á            Prevalence unknown

       ? Common given commercial market

 

*not controversial

8 DSM Paraphilias

 

      1.     Fetishism

      2.     Transvestic fetishism

      3.     Pedophilia*

      4.     Voyeurism*

      5.     Exhibitionism*

      6.     Frotteurism*

      7.     Sexual sadism**

      8.     Sexual masochism

*  dysfunctional = harm to others

**dysfunctional if rape vs. consensual

 

Paraphilias

PEDOPHILIA

 

 Conviction for Pedophilia

 

á   Pedophiles treated with more disdain than other criminals (e.g., serial killer)

 

á   Maligned, rejected, & abused by other inmates

 

á   Publicly humiliated and loss of rights after serving sentence

o  "Megan's Law"

 

Assumption that childhood sex is immoral &  harmful to child = empirical question

Paraphilias

PEDOPHILIA conÕd

 

Long-term Effects of Childhood Sexual Experiences

 

Rind et al. (1998)

 

á    59 studies of adjustment of college students who had sexual experiences as children

 

o  adult-child sex

o  coerced sex with childhood peers

 

GENERALIZABILITY LIMITATION: sample

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

 

Rind et al. (1998) contÕd

 

á    Adjustment

 

o  1% of adult adjustment predicted by childhood sexual experiences

 

o  Family environment (verbal and physical abuse, neglect, conflict) predicts 9% of adult adjustment among those who experienced sex as a child

 

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

 

Rind et al. (1998) contÕd

 

á    Prevalence of childhood sexual experiences

o  Male 14%

o  Female 24%

 

Not rare for children to have sexual experiences with adults or coerced by peers

 

 

 

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

 

Rind et al. (1998) contÕd

 

á    Percentage founding childhood sexual experiences to be negative at the time

 

o  Male 33%

 

o  Female 72%

 

 

Not all children find sexual experiences to be abusive

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

 

Rind et al. (1998) contÕd

 

á    Percentage who find childhood sexual experiences to be negative currently

 

o  Males 26%

 

o  Females 59%

 

Some adults come to view childhood sexual experiences as no longer being negative

 

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

 

Rind et al. (1998) contÕd

 

á    Percentage who find childhood sexual experiences to be positive currently

 

o  Males 43%

 

o  Females 16%

 

Male adults report childhood sexual experiences to be positive more often than do female adults

 

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

Rind et al. (1998) contÕd

 

á    Perceived negative effect of childhood sexual experiences on adult sexual attitudes & performance

 

o  Male 8.5%

 

o  Female 13 %

 

Most adults who had childhood sexual experiences are sexually adjusted

 

Paraphilias

PEDOPHILIA conÕd

Long-term Effects of Childhood Sexual Experiences

Rind et al. (1998) contÕd

 

 

 

Childhood Sex

Neg. as Child

Neg. as Adult

Pos. as Adult

Male

14%

33%

26%

43%

Female

24%

72%

59%

16%

 

Etiology of Paraphilias

 

 

á    Psychoanalytic/Freudian

o  Paraphilias as defense mechanisms

o  Guards ego from dealing with repressed fears at oral & anal stages

o  Represent fixations at pregenital stages of psychosexual development.

Etiology of Paraphilias conÕd

 

á    Cognitive-Behavioral

 

o Classical conditioning with object/activity

o Modeling

o Poor social skills relevant to sex partners

o Reinforcement of unconventional sexual behavior

o Disinformation

o Misattributions

 

Treatment of Paraphilias

 

 

Legal

á   Involuntary commitment to hospitals

á   Imprisonment

á   Court-ordered into outpatient treatment

á   "MeganÕs law"

o Effectiveness highly variable

o  Recidivism increases over time

o  Sex offenders often lack motivation to change

Treatment of Paraphilias conÕd

 

Cognitive Behavioral

 

á    Aversion therapy

á    Satiation

á    0rgasmic reorientation

á    Social skills training

á    Alternative behavior competition

á    Cognitive restructuring

á    Bibliotherapy

 

Treatment of Paraphilias conÕd

 

Biological/ Medical

 

á    Castration

 

á    Drugs to lower testosterone

 

 

 

Sexual & Gender Identity Disorders

 

Sexual Dysfunctions

 

Range of sexual dissatisfaction that

represent inhibitions in the normal

human sexual response cycle.

 

Sexual performance dissatisfaction is

1.               Persistent

2.               Recurrent

3.               Causes marked distress OR
interpersonal problems
Sexual & Gender Identity Disorders

Sexual Dysfunctions

 

Human Sexual Response Cycle

 

1.  Appetitive and desire

 

2.  Excitement and tumescence

 

3.  Orgasm

 

4.  Resolution

 

Sexual & Gender Identity Disorders

Sexual Dysfunctions

 

2 Appetitive/Desire*

 

á    Hypoactive sexual desire disorder**

 

á    Sexual aversion disorder

 

*   Normal desire = ?

 

** Hyperactive desire = ?

 

Sexual Dysfunctions conÕd

 

2 Excitement and tumescence

 

á    Female sexual arousal disorder*

 

á    Male erectile disorder*

 

 

* adequate stimulation = ?

 

 

May reflect failure to learn what is sexually arousing, performance anxiety & organic factors

 

Sexual Dysfunctions conÕd

 

3 Orgasm with tumescence

 

á    Female orgasmic disorder*

 

á    Male orgasmic disorder*

 

*normal stimulation for sexual arousal = ?

 

á   Male premature ejaculation**

 

**Premature = ?

**40% lifetime prevalence =  not rare

**Associated with anxiety

Sexual Dysfunctions conÕd

 

2  Resolution and Pain:  Females only

á     Dyspareunia

 

á   Vaginismus

o associated with history of rape/molestation

 

 

 

 

 

 

Etiology of Sexual Dysfunctions

 

 

Masters and Johnson (1960's+)

 

á    Current Factors

 

 

 The adoption of a spectator role

 

 

 Fear of performance

 

Etiology of Sexual Dysfunctions conÕd

Masters and Johnson (1960's+) conÕd

 

 

á   Historical Factors

 

Religious orthodoxy

 

Inadequate counseling

 

Excessive intake of alcohol

 

Biological causes (e.g. diabetes)

 

 

Etiology of Sexual Dysfunctions conÕd

Masters and Johnson (1960's+) conÕd

 

á   Other etiological factors

 

Partner/marital conflict

The meaning of a sexual problem for a person

 e.g., reinforcement

Lack of knowledge or skill

Poor communication by partners

Fear of acquiring sexually transmitted diseases

Treatment of Sexual Dysfunctions

 

 

Behavioral & cognitive-behavioral

 

Masters and Johnson

 

1st: ban on sexual activity

 

2nd: discussion of couple's sexual value system

 

3rd: sensate focus

 

4th: specific instructions in intercourse

 

Treatment of Sexual Dysfunctions conÕd

 

Other techniques:

 

á    Anxiety reduction

á    Sensory-awareness  (e.g., "stop-start" for pre-mature ejaculation)

á    Communication training

á    Couples therapy

á    Behavior rehearsal with surrogate

 

Treatment of Sexual Dysfunctions conÕd

Other techniques con'd:

 

á   Biological and Medical

 

o Hormones

o Anti-anxiety drugs

o Anti-depressant drugs

o Penis implants

o Penis vacuum pump

o Vasodilators (e.g.,Viagra)

Sexual & Gender Identity Disorders

Sexual Dysfunctions

 

Sex Abuse Treatment Center

 

55 Merchant Street, 22nd Floor

 

Honolulu, HI 96813

 

Emergency 24-Hour Crisis Hotline: 524-7273.

 

www.kapiolani.org/facilities/programs-sex.html