1. Sexual and Gender Identity Disorders
Chapter 9
Sexual and Gender Identity Disorders

2. Sexual and Gender Identity Disorders
What is “normal” vs. “abnormal” sexual behavior?
Normative facts and statistics
Cultural considerations
Gender differences in sexual behavior and attitudes
Technology Tip: Sexual Health.com. This web site provides useful resources regarding health and sexual behavior, including links to current research and news about available treatments.
Technology Tip: Kinsey Institute for Research in Sex, Gender, and Reproduction, Inc. This is an excellent research website, that includes links to current research publications.

3. FIGURE 9. 1 Results of a survey of male sexual practices
FIGURE Results of a survey of male sexual practices. (Data from Billy, J.O.G.,Tanfer, K., Grady, W. R., & Klepinger, D. H., The sexual behavior of men in the United States. Family Planning Perspectives, 25, 52–60.)

4. Sexual and Gender Identity Disorders
The development of sexual orientation
Complex interaction of bio-psycho-social influences
The example of homosexuality
DSM-IV-TR sexual and gender identity disorders
Gender identity disorder
Sexual dysfunctions
Paraphilias
Technology Tip: Sexual Disorders and Dysfunctions. This site has links to a variety of topics related to sexual behavior and sexual dysfunctions.

5. Defining Gender Identity Disorder
Clinical overview – trapped in the body of the wrong sex
Assume the identity of the desired sex
Goal is not sexual
Causes are unclear
Gender identity develops between 18 months and three years of age
Technology Tip: Society for the Scientific Study of Sexuality. An international organization dedicated to the advancement of knowledge about sexuality. It is the oldest organization of professionals interested in the study of sexuality in the U.S. This site details the importance of both production of quality research and the clinical educational, and social applications of research related to all aspects of sexuality.

6. Defining Gender Identity Disorder
Sex-reassignment as a treatment
Who is a candidate? – Basic prerequisites before surgery
75% report satisfaction with new identity
Female-to-male conversions adjust better
Psychosocial treatment
Realign psychological gender with biological sex
Few large scale studies
Treatment of intersexuality
Technology Tip: ABC’s website for 20/20 offers a video on gender identity disorder:
Technology Tip: The following website was created by a transsexual psychologist and provides information, links, and personal essays:

7. Overview of Sexual Dysfunctions
Involve desire, arousal, and/or orgasm
Pain associated with sex can lead to additional dysfunction
Technology Tip: HisandHerHealth Is a highly-credentialed, HON-registered site providing medical information and articles on the causes and treatments of male and female sexual dysfunction, prostate, incontinence, fertility and related issues. The site includes videos, moderated chat rooms, bulletin board, and scheduled chats with a doctor.

8. Overview of Sexual Dysfunctions
Males and females experience parallel versions of most dysfunctions
Affects about 43% of all females and 31% of males
Most prevalent class of disorder in the United States

9. Overview of Sexual Dysfunctions
Classification of sexual dysfunctions
Lifelong vs. acquired
Generalized vs. situational
Psychological factors alone
Psychological factors combined with medical condition

10. FIGURE 9. 2 The human sexual response cycle. (Based on Kaplan, H. S
FIGURE 9.2 The human sexual response cycle. (Based on Kaplan, H. S., 1979, Disorders of sexual desire, New York, NY: Brunner/Mazel, and Masters, W. H., & Johnson, V. E., 1966, Human sexual response, Boston, MA: Little, Brown.) .

11. Sexual Desire Disorders: An Overview
Hypoactive sexual desire disorder
Little or no interest in any type of sexual activity
Masturbation, sexual fantasies, and intercourse are rare
Accounts for half of all complaints at sexuality clinics
Affects 22% of women and 5% of men

12. Sexual Desire Disorders: An Overview
Sexual aversion disorder – also little interest in sex
Extreme fear, panic, or disgust
Related to physical or sexual contact
10% of males
Report panic attacks during attempted sexual activity

13. Sexual Arousal Disorders
Male erectile disorder
Difficulty achieving and maintaining an erection
Female sexual arousal disorder
Difficulty achieving and maintaining adequate lubrication
Technology Tip: Impotence. An elaborate description of impotence provided by the National Institutes of Health. Type in the search word "impotence."

14. FIGURE 9.3 Estimated prevalence and severity of erectile dysfunction in a sample of 1,290 men between 40 and 70 years of age. (Reprinted, with permission, from Feldman et al., Impotence and its medical and psychosocial correlates: Results of the Massachusetts male aging study. Journal of Urology, 51, 54–61.

15. Sexual Arousal Disorders
Associated features of sexual arousal disorders
Problem is arousal, not desire
Problem affects about 5% of males, 14% of females
Males are more troubled by the problem than females
Erectile problems are the main reason males seek help

16. Orgasm Disorders Inhibited orgasm: Female and male orgasmic disorder
No orgasm despite adequate sexual desire and arousal
Rare condition in adult males
Most common complaint of adult females

17. Orgasm Disorders Premature ejaculation Ejaculation occurring too soon
Most prevalent sexual dysfunction in adult males
Affects 21% of all adult males
Most common in younger, inexperienced males
Problem tends to decline with age

18. Sexual Pain Disorders Defining features Dyspareunia
Marked pain during intercourse
Dyspareunia
Extreme pain during intercourse
Affects 1% to 5% of men and about 10% to 15% of women
Adequate sexual desire
Adequate ability to attain arousal and orgasm
Must rule out medical reasons for pain

19. Sexual Pain Disorders Vaginismus Limited to females
Outer third of the vagina undergoes involuntary spasms
Complaints include
Feeling of ripping, burning, or tearing
Affects over 6% of women seeking treatment
Prevalence rates are higher
In more conservative countries and subgroups

20. Assessing Sexual Behavior
Comprehensive interview
Detailed history of sexual behavior, lifestyle, and associated factors
Medical examination
Must rule out potential medical causes of sexual dysfunction

21. Assessing Sexual Behavior
Psychophysiological evaluation
Exposure to erotic material
Determine extent and pattern of sexual arousal
Males – penile strain gauge
Females – vaginal photoplethysmograh

22. Causes and Treatment of Sexual Dysfunction
Biological contributions
Physical disease, medical illness, prescription medications
Use and abuse of alcohol and other drugs
Anti-hypertensive medication

23. Causes and Treatment of Sexual Dysfunction
Psychological contributions
The role of “anxiety” vs. “distraction”
The nature and components of performance anxiety
Psychological profiles associated with sexual dysfunction

24. Causes and Treatment of Sexual Dysfunction
Social and cultural contributions
Erotophobia – learned negative attitudes about sexuality
Negative or traumatic sexual experiences
Deterioration of interpersonal relationships, lack of communication
Interaction of psychological and physical factors

25. FIGURE 9. 4 A model of functional and dysfunctional sexual arousal
FIGURE 9.4 A model of functional and dysfunctional sexual arousal. (Adapted from Barlow, D. H., Causes of sexual dysfunction: The role of anxiety and cognitive interference. Journal of Consulting and Clinical Psychology, 54, 140–148.)

26. Treatment of Sexual Dysfunction
Education alone
Is surprisingly effective
Masters and Johnson’s psychosocial intervention
Education
Eliminate performance anxiety
Sensate focus and nondemand pleasuring
Technology Tip: Masters and Johnson. The web site of Masters and Johnson with information on their current research and treatment interests.

27. Treatment of Sexual Dysfunction
Additional psychosocial procedures
Squeeze technique – premature ejaculation
Masturbatory training – female orgasm disorder
Use of dilators – vaginismus
Exposure to erotic material – low sexual desire problems

28. Medical Treatment of Sexual Dysfunction
Erectile dysfunction
Viagra – is it really the wonder drug?
Injection of vasodilating drugs into the penis
Testosterone
Penile prosthesis or implants
Vascular surgery
Vacuum device therapy
Few medical procedures exist for female sexual dysfunction

29. Paraphilias: Clinical Descriptions and Causes
Nature of paraphilias – misplaced sexual attraction and arousal
Focused on inappropriate people, or objects
Often multiple paraphilic patterns of arousal
High comorbidity
With anxiety, mood, and substance abuse disorders
Technology Tip: DSM-IV-TR Diagnostic Information Contains diagnostic criteria for just about all DSM-IV-TR disorders.

30. Paraphilias: Clinical Descriptions and Causes
Main types of DSM-IV-TR paraphilias
Fetishism
Voyeurism
Exhibitionism
Transvestic fetishism
Sexual sadism and masochism
Sadistic rape
Pedophilia and incest

31. FIGURE 9.5 Models of paraphilia.

32. Fetishism Fetishism Examples
Sexual attraction to nonliving objects
Objects can be inanimate and/or tactile
Examples
May include rubber, hair, feet, objects such as shoes
Numerous targets of fetishistic arousal, fantasy, urges, and desires

33. Voyeurism and Exhibitionism
Observing an unsuspecting individual undressing or naked
Risk associated with “peeping” is necessary for sexual arousal
Exhibitionism
Exposure of genitals to unsuspecting strangers
Element of thrill and risk is necessary for sexual arousal

34. Transvestic Fetishism
Sexual arousal with the act of cross-dressing
Males may show highly masculine compensatory behaviors
Most do not show compensatory behaviors
Many are married and the behavior is known to spouse

35. Sexual Sadism and Sexual Masochism
Inflicting pain or humiliation to attain sexual gratification
Sexual masochism
Suffer pain or humiliation to attain sexual gratification

36. Sexual Sadism and Sexual Masochism
Relation of sadism and rape
Some rapists are sadists
Most rapists do not show paraphilic patterns of arousal
Rapists tend to show sexual arousal to violent sexual and non-sexual material

37. Pedophilia Overview Pedophiles – sexual attraction to young children
Incest – sexual attraction to one’s own children
Victims
Male and/or female children or very young adolescents
Pedophilia is rare, but not unheard of, in females
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38. Pedophilia Associated features Most perpetrators are male
Incestuous males may be aroused by adult women
Male pedophiles are not aroused by adult women
Most rationalize the behavior
Often engage in other moral compensatory behavior
Technology Tip: For more information, visit the Association for the Treatment of Sexual Abusers website:

39. FIGURE 9.6 Ratings of Tony’s incestuous urges.

40. Pedophilia: Causes and Assessment
Causes of pedophilia
Associated with sexual and social problems and deficits
Patterns of inappropriate arousal and fantasy
May be learned early in life
High sex drive, coupled with suppression of urges

41. Pedophilia: Causes and Assessment
Psychophysiological assessment of pedophilia
Deviant patterns of sexual arousal
Desired sexual arousal to adult content
Social skills deficits
Have difficulties forming appropriate adult relationships

42. Pedophilia: Psychosocial Treatment
Psychosocial interventions
Most are behavioral
Target deviant and inappropriate sexual associations
Covert sensitization – imagining aversive consequences
Orgasmic reconditioning – masturbation plus appropriate stimuli
Family/marital therapy – address interpersonal problems
Coping and relapse prevention – self-control and risk management

43. Pedophilia: Psychosocial Treatment
Efficacy of psychosocial interventions
About 75% to 95% of cases show improvement
Poorest outcomes – rapists/multiple paraphilias
Run a chronic course with high relapse rates

44. Pedophilia: Drug Treatments
Medications: The equivalent of chemical castration
Often used for dangerous sexual offenders
Types of available medications
Cyproterone acetate
Anti-androgen, reduces testosterone, sexual urges and fantasy
Medroxyprogesterone acetate
Depo-provera, also reduces testosterone

45. Pedophilia: Drug Treatments
Efficacy of medication treatments
Drugs work to greatly reduce sexual desire, fantasy, arousal
Relapse rates are high with medication discontinuation
On the spectrum

46. Summary of Sexual and Gender Identity Disorders
Gender identity and gender identity disorder
Problem is not sexual
Feeling trapped in body of wrong sex
Sexual dysfunctions are common in men and women
Problems with desire, arousal, and/or orgasm

47. Summary of Sexual and Gender Identity Disorders
Paraphilias represent inappropriate sexual attraction
Desire, arousal, and orgasm gone awry
Available psychosocial and medical treatment options
Are generally efficacious
Comprehensive assessment and treatment approaches are best