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  • MATCH WITH CRITERION
  • Could leave criteria as they are but make them more stringent.But, still the problem of dichotomy disregarding the wide variety of gender identity related phenomena clinicians encounter.-KEEPING Dx of some sort allows insurance coverage of reassignment surgery
  • Insurance Coverage problemsOr….-Change GID from psychological to neurologic or neurocognitive disorder -Remove GIV from DSM and re-label as a medical conditionIn non-DSD GIV’s reproductive tract and body are healthy Sweden has removed GIV but retained transsexualism to preserve access to medical procedures for gender reassignment
  • 11 year old Jazz… 20/20 started following her when she was 6….Documentary: “I am Jazz: A Family in Transition”4:23-5:23 (stop when it shows Dad)

Psychopathology ppt Presentation Transcript

  • 1. Sexual and GenderIdentity DisordersKellie Cooper, Heather Munsche, DaniellePainter, & Lisa Zbizek-Nulph
  • 2. • Gender Identity Disorder (Heather)• Sexual Pain Disorders -Dyspareunia• Sexual Arousal Disorder (Kellie) -Female Sexual Arousal Disorder -Male Erectile Disorder• Orgasmic Disorders -Premature Ejaculation• Paraphilias -PedophiliaOverview
  • 3. DSM-IV-TR:• Core Criteria in DSM includes: • Cross-gender identification • Desire to live as member of the other sex • Sense of inappropriateness in the gender role belonging to one’s natal sex • Discomfort about one’s assigned sex • Desire to have sex characteristics of the other sex • Discomfort about one’s anatomic sex • Wish to get rid of one’s natal sex characteristicsGender Identity Disorder
  • 4. • GID vs. Transgender • Current formulation – wish to completely alter body (complete sex reassignment) option for having diagnosis • Inability of current criteria to capture spectrum of gender variance phenomena • Dichotomous rather than dimensional idea of gender • Netherlands – 10% asked for partial medical treatment • Risk of unnecessary physical examinations-C • Gender dysphoria occurs in people with DSD (disorders of sex development) as wellCriticisms of DSM-IV-TR
  • 5. • Necessity of D criterion – impairment or distress • Many with GID have psychiatric problems but why? • Social stigma role• Many with GID function well but still desire reassignment • If not distressed, do not qualify for Dx, ineligible for sex reassignment• Diagnosis still applies to post-operative individuals • Pathologized for life – should exclude those no longer gender dysphoric
  • 6. • Rename: Gender Dysphoria • More neutral connotation• New diagnostic indicators (Only 1 for Dx) • Strong sense of discomfort with the gender role associated with one’s assigned gender • Strong discomfort with one’s primary and/or secondary sex characteristics, because they do not match one’s gender identity • Strong desire for primary and/or sex characteristics that match one’s gender identity • Distress causes by a strong desire to live in the gender role of the other gender and/or to be perceived by others as a member of the other gender (or some alternative gender different from one’s assigned gender) • Distress caused by a strong identification with the other gender (or some alternative gender different from one’s assigned gender) Recommendations
  • 7. • GID could be understood as CNS-limited form of DSD without involvement of reproductive tract• There may be genetically based systemic sex-hormone abnormalities that do not cause abnormalities of the reproductive anatomy but nevertheless influence brain & behavior• Some feel that (Gender Identity Variation) is completely biologically-bounded • Is it “natural” to want to take functioning anatomy and replace it with characteristics of the other gender and impose infertility?• Most treatment involves hormones & surgery, not psychotherapyOr…depathologize completely
  • 8. • http://www.youtube.com/watch?v=_Wh6NecfMiE• Currently: -Criteria are worded differently for boys and girls -Requires statement that he or she wants to be other genderChildhood GID
  • 9. • Leave criteria as are (change some wording) • Shows discriminative validity • Why not: ability to make Dx in absence of repeated verbal statements that one wishes to be the other sex• Tighten criteria so A has to include all 5 parameters • Some kids might want to be the other sex but don’t verbalize it, would lead to social problems• Eliminate criteria of specific behaviors – new set of criteria focusing on different manifestations of gender dysphoria• Zucker recommends 2 – may decrease number eligible for Dx. Combine A & B criteria. Desire to be of the other sex necessary for diagnosis. Lower bound duration criterion of 6 months. • Would alert clinician it is not a transitory thingRecommendations-Child
  • 10. Dyspareunia
  • 11. DSM-IV-TR: • C. The person is at least age 16 years and at least 5 years older • A. Over a period of at least 6 than the child or children in months, recurrent, intense Criterion A sexually arousing fantasies, sexual urges, or behaviors • Specify if: involving sexual activity with • Sexually Attracted to Males a prepubescent child or • Sexually Attracted to Females children (generally age 13 or • Sexually Attracted to Both younger) • Specify if: • B. The person has acted on • Limited to Incest these sexual urges, or the sexual urges or fantasies cause • Specify if: marked distress or • Exclusive Type (attracted only interpersonal difficulty to children) • Nonexclusive TypePedophilia
  • 12. Arguments for change: • Diagnostic criteria based on guesswork • Studies that have investigated • Field trials for DSM-III these criteria found them to be included 3 patients “mediocre or poor” • Paraphilias not included (Blanchard, 2011) in field trials for DSM- III-R or DSM-IVParaphilias
  • 13. Proposed Changes:• All Paraphilic Disorders now include two new specifiers: In a Controlled Environment and In Remission• Rename Paraphilias chapter Paraphilic Disorders• Pedophilic Disorder - addition of a Hebephilic SubtypeParaphilias
  • 14. Criticism 1: Response: • Remove “sexual acts” • “repeated sexual acts from Criterion A involving children are • First and Frances (2008) practically indispensable as a argue that sexual acts diagnostic sign of alone then cause pedophilia” (Blanchard, professionals to diagnose a 2009) person with a mental • Sometimes this history is the only thing we can use in diagnosing disorder without other • Can’t rely on self-report evidence • “blurs the distinction between mental disorder and criminality”Pedophilia
  • 15. Criticism 2: • Response: • Criterion A too vague • Go back to DSM-III • What constitutes • “the act or fantasy of recurrent? engaging in sexual • What constitutes activity with prepubertal intense? children is a repeatedly preferred or exclusive method of achieving sexual excitement” • But how do you assess preferences?Pedophilia
  • 16. Criticism 3: • Need more research • Why 6 months for time in this area! interval?Pedophilia
  • 17. Criticism 4: Response: • How do we distinguish • Specify a # of between pedophile and occurrences during a child molester? time period and use as a • Not one in the same cutoff • Child molester could = • Actually has empirical antisocial PD + support opportunity • 61% w/ sexual offense of 3 or more children had greater penile tumescence to pictures of children • 42% of 2 or more • 30% of 1 or morePedophilia
  • 18. Criticism 5: Response: • Should we account for • Specify acute or difference between chronic person offending against 1 child versus many?Pedophilia
  • 19. Criticism 6: • Wording in Criterion B makes it seem necessary Response: to be distressed or • DSM-5 could distinguish impaired by pedophilia between paraphilias and to have disorder paraphilic disorders • DSM-IV-R has added societal impairments to solve this • Is this sufficient? What if person doesn’t act on feelings and doesn’t impact community?Pedophilia
  • 20. Criticism 7: Response: • Snyder, 2000 found the • Should there be a average age of sex diagnostic category for victims is 14 – in those interested pubescent range (as primarily in pubescent cited in Blanchard, individuals? 2009) • AKA Hebephilia • But is this pathological? • From an evolutionary point of view - NO! (Blanchard, 2010)Pedophilia
  • 21. • A. The person is equally or more attracted sexually to children under the age of 15 than to physically mature adults, as indicated by self-report, laboratory testing, or behavior. • B. The person is distressed or impaired by these attractions, or the person has sought sexual stimulation from children under 15 on three or more separate occasions. • C. The person is at least 5 years older than the child or children in Criterion A. • Specify if: • Sexually attracted to Children younger than 11 (Pedophilic Type) • Sexually attracted to Children Age 11-14 (Hebephilic Type) • Sexually attracted to Both (Pedohebephilic Type) • Specify if: • Sexually attracted to Males • Sexually attracted to Females • Sexually attracted to bothProposed Criteria for PedophilicDisorder
  • 22. • The APA draft guidelines for making changes to DSM-V: • (1) to distinguish between psychiatric syndromes for purposes of guiding the most effective treatment and management; • (2) to reduce confusion of syndromes with each other; • (3) to take into account co-morbid symptoms which affect the outcome of treatment in the most effective manner; (4) to facilitate ease of use and promote clinical utility; (5) to demonstrate validity on as many levels as possible.
  • 23. Approved Changes: • Paraphilias chapter renamed Paraphilic DisordersParaphilias
  • 24. • 163. Zucker KJ. The DSM Diagnostic Criteria for Gender Identity Disorder in Children. Archives of Sexual Behavior, 2010; 39:477-498.• 164. Cohen-Kettenis PT, Pfäfflin F. The DSM Diagnostic Criteria for Gender Identity Disorder in Adolescents and Adults. Archives of Sexual Behavior, 2010; 39:499-513.• 165. Meyer-Bahlburg HFL. From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas in Conceptualizing Gender Identity Variants as Psychiatric Conditions. Archives of Sexual Behavior, 2010; 39:461-476.• 176. Drescher J. Queer Diagnoses: Parallels and Contrasts in the History of Homosexuality, Gender Variance, and the Diagnostic and Statistical Manual. Archives of Sexual Behavior, 2010; 39:427-460.Blanchard, R. (2011). A brief history of field trials of the DSM diagnostic criteria for paraphilias [Letter to the Editor]. Archives of Sexual Behavior, 40, 861-862.• Blanchard, R. (2009). The DSM diagnostic criteria for pedophilia. Archives of Sexual Behavior, 39, 304-316.• Blanchard, R. (2010). The fertility of hebephile and the adaptationist argument against including hebephilia in DSM-5. Archives of Sexual Behavior, 39, 817-818.References