Lecture 8 sexual and gender identity disorders
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Lecture 8 sexual and gender identity disorders Lecture 8 sexual and gender identity disorders Presentation Transcript

  • P R O F . D O M I N G O O . B A R C A R S E A S S O C I A T E P R O F E S S O R O F P S Y C H O L O G Y D E P A R T M E N T O F P S Y C H O L O G Y C O L L E G E O F A R T S A N D S C I E N C E S LECTURE 8: SEXUAL AND GENDER IDENTITY DISORDERS
  • What is Normal Sexuality?  Patterns of sexual behavior, both heterosexual and homosexual, vary around the world in terms of both behavior and risks. Approximately 20% of individuals who have been surveyed engage in sex with numerous partners , which puts them at risks for sexually transmitted diseases such as AIDS. Recent surveys also suggest that as many as 60% of Amrecian college females practice unsafe sex by not using appropriate condoms.  Three types of disorders are associated with sexual functioning and gender identity: gender identity disorder, sexual dysfunctions, and paraphilias.
  • What is Gender Identity Disorder  Gender identity disorder is a dissatisfaction with one’s biological sex and the sense that one is really the opposite gender (for example, a woman trapped in a man’s body). A person develops gender identity between 18 months and 3 years of age, and it seems that both appropriate gender identity and mistaken gender identity have biological roots influenced by learning.  Treatment for adults may include sex reassignments surgery integrated with psychological approaches.
  • DSM-IV-TR TABLE 10.1 CRITERIA FOR GENDER IDENTITY DISORDER  A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:  1. Repeatedly stated desire to be, or insistence that he or she is, the other sex  2. in boys, preference for cross dressing of simulating female attire; in girls insistence on wearing only stereotypical musculine clothing.
  • DSM-IV-TR TABLE 10.1 CRITERIA FOR GENDER IDENTITY DISORDER  A  3. Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex  4. Intense desire to participate in the stereotypical games and pastimes of the other sex.  5. Strong preference for playmates of the other sex. In adolescence and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
  • DSM-IV-TR TABLE 10.1 CRITERIA FOR GENDER IDENTITY DISORDER  B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to a have a penis, or aversion toward rough-to-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to stimulate the other sex) or belief that he or she was born the wrong sex.
  • DSM-IV-TR TABLE 10.1 CRITERIA FOR GENDER IDENTITY DISORDER  C. The disturbance is not concurrent with a physical intersex condition.  D. The disturbance causes clinically distress or impairment in social, occupational, or other important areas of functioning.  Specify if (for sexually mature individuals):  Sexually attracted to males  Sexually attracted to females  Sexually attracted to both  Sexually attracted to neither
  • OVERVIEW OF SEXUAL DYSFUNCTIONS  Sexual dysfunction includes a variety of disorders in which people find it difficult to function adequately during sexual relations.  Specific sexual dysfunctions include disorders of sexual desire (hypoactive sexual desire disorder and sexual aversion disorder) in which interest in sexual relations is extremely low or nonexistent; disorders of sexual arousals (male erectile disorder and female sexual arousal disorder) in which achieving or maintaining adequate penile erection or vaginal lubrication is problematic; and orgasmic disorders (female orgasmic disorder and male orgasmic disorder) in which orgasm occurs too quickly or not at all. The most common disorder in this category is premature ejaculation, which occurs in males; inhibited orgasm is commonly seen in females.
  • OVERVIEW OF SEXUAL DYSFUNCTIONS  Sexual pain disorders, in which unbearable pain is associated with sexual relations, include dyspareunia and vaginismus.
  • THE HUMAN SEXUAL RESPONSE  DESIRE PHASE. Sexual urges occur in response to sexual cues or fantasies.  AROUSAL PHASE. A subjective sense of sexual pleasure and physiological signs of sexual arousal: in males, penile tumescence (increased flow of blood into the penis); in females, vasocongestion (blood pools in the pelvic area) leading to vaginal lubrication and breast tumescence (erect nipples).  PLATEAU PHASE. Brief period occurs before orgasm.
  • THE HUMAN SEXUAL RESPONSE  ORGASM PHASE. In males, feelings of the inevitability of ejaculation, followed by ejaculation; in females, contractions of the walls of the lower third of the vagina.  RESOLUTION PHASE. Decrease in arousal occurs after orgasm (particularly in men)
  • CATEGORIES OF SEXUAL DYSFUNTION AMONG MEN AND WOMEN TYPE OF DISORDER MEN WOMEN DESIRE Hypoactive sexual desire disorder (little or no desire to have sex) Sexual aversion disorder (aversion to and avoidance of sex) Hypoactive sexual desire disorder (little or no desire for sex) Sexual aversion disorder (aversion to and avoidance of sex) AROUSAL Male erectile disorder (difficulty attaining or maintaining erections) Female sexual arousal disorder (difficulty attaining or maintaining lubrication or swelling response) ORGASM Inhibited male orgasm; premajure ejaculation Inhibited female orgasm PAIN Dyspareunia (pain associated with sexual activity) Dyspareunia (pain associated with sexual activity); Vaginismus (muscle spasms in the vagina that interfere with penetration)
  • DSM-IV-TR TABLE 10.2 CRITERIA FOR HYPOACTIVE SEXUAL DESIRE DISORDER  A. Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgement of decifiency 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.
  • DSM-IV-TR TABLE 10.2 CRITERIA FOR HYPOACTIVE SEXUAL DESIRE DISORDER  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 (e.g., a drug of abuse, a medication) or a general medical condition.  Specify type:  Lifelong Type  Acquired Type  Specify type :  Generalized Type  Situational Type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.3 CRITERIA FOR 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).  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.4 DIAGNOSTIC CRITERIA FOR SEXUAL AROUSAL DISORDER  Female  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 cause 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 (e.g., a drug of abuse, a medication) or a general condition.
  • DSM TABLE 10.4 DIAGNOSTIC CRITERIA FOR SEXUAL AROUSAL DISORDER  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.4 DIAGNOSTIC CRITERIA FOR SEXUAL AROUSAL DISORDER  Male  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 erectile dysfunction is not better accounted for by another Axis I Disorder (other than a sexual dysfunction) and is not due to exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition)
  • DSM-IV-TR TABLE 10.4 DIAGNOSTIC CRITERIA FOR SEXUAL AROUSAL DISORDER  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.5 DIAGNOSTIC CRITERIA FOR ORGASMIC DISORDER  Female  A. Persistent and recurrent delay, or absence of, orgasm following a normal sexual excitement phase. Woman exhibit wide variability in the type of insensitivity 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.
  • DSM-IV-TR TABLE 10.5 DIAGNOSTIC CRITERIA FOR ORGASMIC DISORDER  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 (e.g., a drug of abuse, a medication) or a general medication.  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.5 DIAGNOSTIC CRITERIA FOR ORGASMIC DISORDER  Male  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.
  • DSM-IV-TR TABLE 10.5 DIAGNOSTIC CRITERIA FOR ORGASMIC DISORDER  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 (e.g., a drug of abuse, a medication) or a general medical condition.  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.6 DIAGNOSTIC CRITERIA FOR 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 (e.g., withdrawal from opioids).  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors DSM-IV-TR TABLE 10.6 DIAGNOSTIC CRITERIA FOR PREMATURE EJACULATION
  • DSM-IV-TR TABLE 10.7 DIAGNOSTIC CRITERIA FOR SEXUAL PAIN DISORDER  Dyspareunia  A. Recurrent or persistent genital pain associated with sexual intercourse in either a male or a 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 (e.g., a drug of abuse, a medication) or a general medical condition.
  • DSM-IV-TR TABLE 10.7 DIAGNOSTIC CRITERIA FOR SEXUAL PAIN DISORDER  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • DSM-IV-TR TABLE 10.7 DIAGNOSTIC CRITERIA FOR SEXUAL PAIN DISORDER  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 (e.g., somatization disorder) and is not due exclusively to the direct physiological effects of a general medical condition.
  • DSM-IV-TR TABLE 10.7 DIAGNOSTIC CRITERIA FOR SEXUAL PAIN DISORDER  Specify type:  Lifelong type  Acquired type  Specify type:  Generalize type  Situational type  Specify  Due to psychological factors  Due to combined factors
  • MYTHS OF SEXUALITY Myths of Female Sexuality Myths of Male Sexuality 1. Sex is only for woman under 30. 2. Normal women have an orgasm everytime they have sex. 3. All women can have multiple orgasms. 4. Pregnancy and delivery reduce women’s sexual responsiveness. 5. A woman’ sex life ends with menopause. 6. There are different kinds of orgasm related to woman’s personality: Vaginal orgasms are more feminine and mature than clitoral orgasms. 7. A sexually responsive woman can always be turned on by her partner. 8. Nice women aren’t aroused by erotic books or films. 9. You are frigid if you don’t like the more exotic forms of sex. 10. If you can’t have an orgasm quickly and easily, there’s something wrong with you. 11. Feminine women don’t initiate sex or become wild and unrestrained during sex. 12. Double jeopardy: You’re frigid if you don’t want sex and wanton if you do. 13. Contraception is a woman’s responsibility, and she’s just making up excuses is she says contraceptive issues are inhibiting her sexuality. 1. We’re liberated folks who are comfortable with sex. 2. A real man isn’t into sissy stuff like feelings and communicating. 3. All touching is sexual or should lead to sex. 4. A man is always interested in and always ready for sex. 5. Bigger is better. 6. Sex is centered on a hard penis and what’s done with it. 7. Sex equals intercourse. 8. A man should be able to make the earth move for his partner, or at least knock her socks off. 9. Good sex requires orgasm. 10.Men don’t have to listen to women in sex. 11.Good sex is spontaneous, with no planning and not talking. 12.Real men don’t have sex problems. 13.Real men should be able to last all night.
  • CAUSES AND TREATMENT OF SEXUAL DYSFUNCTIONS  Sexual dysfunction is associated with socially transmitted negative attitudes about sex, interacting with current relationship difficulties, and anxiety focused on sexual ability.  Psychosocial treatment of sexual dysfunctions is generally successful but not readily available. In recent years, various medical approaches have become available, including the drug Viagra. These treatments focus mostly on male erectile dysfunction and are promising.
  • PARAPHILIA: CLINICAL DESCRIPTIONS  Paraphilia is sexual attraction to inappropriate people, such as children, or to inappropriate objects, such as articles of clothing.  The paraphilias include fetishism, in which sexual arousal occurs almost exclusively in the context of inappropriate objects or individuals; exhibitionism, in which sexual gratification is attained by exposing one’s genitals to unssuspecting strangers; voyeurism, in which sexual arousal is derived from observing unsuspecting individuals undressing or naked; transvestic fetishism, in which individuals are sexually aroused by wearing clothing of the opposite sex; sexual sadism, in which sexual arousal is associated with experiencing pain or humiliation;; sexual masochism, in which sexual arousal is associated with experiencing pain or humiliation; and pedophilia, in which there is a strong sexual attraction toward children. Incest is a type of pedophilia in which the victim is related, often a son or a daughter.
  • PARAPHILIA: CLINICAL DESCRIPTIONS  The development of paraphilia is associated with deficiencies in consensual adult sexual arousal, deficiencies in consensual adult social skills, deviant sexual fantasies that may develop before or during puberty, and attempts by the individual to suppress thoughts associated with these arousal patterns.
  • ASSESSING AND TREATING PARAPHILIA  Psychosocial treatments of paraphilia, including covert sensitization, orgasmic reconditioning, and relapse prevention, seem highly successful but are available only in specialization clinics.
  • DSM-IV-TR TABLE 10.8 DIAGNOSTIC CRITERIA FOR FROTTEURISM  A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving touching and rubbing against a nonconsenting person.  The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
  • DSM-IV-TR TABLE 10.9 DIAGNOSTIC CRITERIA FOR FETISHISM  A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the use of nonliving objects (e.g., undergarments).  B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  C. The fetish objects are not limited to articles of female clothing used in cross-dressing (as in transvestic fetishism) or devices designed for the purpose of tactile genital stimulation (e.g., a vibrator)
  • DSM-IV-TR TABLE 10.10 CRITERIA FOR VOYEURISM AND EXHIBITIONISM  Voyeurism  A. Over a period of at least 6 months, 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.  B. The person has acted on these sexual urges, or the sexual urges or fantasies cause marked distress or interpersonal difficulty.
  • DSM-IV-TR TABLE 10.10 CRITERIA FOR VOYEURISM AND EXHIBITIONISM  Exhibitionism  A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the exposure of one’s genitals to an unsuspecting stranger.  B. The person has acted on these sexual urges, or the sexual urges or fantasies caused marked distress or interpersonal difficulty.
  • DSM-IV-TR TABLE 10.11 CRITERIA FOR TRANSVESTIC FETISHISM  A. Over a period of at least 6 months in a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing.  B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.  Specify if:  With gender dysphoria: If the person has persistent discomfort with gender role or identity.
  • DSM-IV-TR TABLE 10.12 CRITERIA SEXUAL FOR SADISM AND SEXUAL MASOCHISM  Sexual Sadism  A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not stimulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.  B. The person has acted on these sexual urges with a non-consenting person, or the sexual urges or fantasies causes marked distress or interpersonal difficulty.
  • DSM-IV-TR TABLE 10.12 CRITERIA SEXUAL FOR SADISM AND SEXUAL MASOCHISM  Sexual Masochism  A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the act (real, not stimulated) or being humiliated, beaten, bound, or otherwise made to suffer.  B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • DSM-IV-TR TABLE 10.13 CRITERIA PEDOPHILIA  A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prebuscent child or children (generally age 13 years or younger).  B. The person has acted on these sexual urges, or the sexual urges or fantasies caused marked distress or interpersonal difficulty.  C. The person is at least age 16 years and at least 5 years older than the child or children in criterion A.  Note: Bo not include an individual in late adolescence involved in an ongoing sexual relationship with a 12 or 13 year old.
  • DSM-IV-TR TABLE 10.13 CRITERIA PEDOPHILIA  Specify if:  Sexually attracted to males  Sexually attracted to females  Sexually attracted to both  Specify if:  Limited to incest  Specify type:  Exclusive type (attracted only to children)  Non exclusive type
  • DSM-IV-TR TABLE 10.14 CRITERIA FOR PARAPHILIA NOT OTHERWISE SPECIFIED  This category is included for coding paraphilias that do not meet the criteria for any of the specific categories. Examples include, but are not limited to, telephone scatologia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on part of body), zoophilia (animals), coprophilia (feces), klismaphilia (enemas), and urophilia (urine).
  • A MODEL OF THE DEVELOPMENT OF PARAPHILIA PARAPHILIA Repeated attempts to inhibit undesired arousal and behavior resulting in (paradoxical) increase in paraphilic thoughts, fantasies, and behavior Inappropriate sexual fantasies repeatedly associated with masturbatory activities and strongly reinforced Early inappropriate sexual associations or experiences (some accidental and some vicarious) Possible inadequate development of consensual adult arousal patterns Possible inadequate development of appropriate social skills for relating to adults
  • ASSESSING SEXUAL BEHAVIOR  INTERVIEWS  COMPLETE MEDICAL EVALUATION  PSYCHOPHYSIOLOGICAL ASSESSMENT
  • EXPLORING SEXUAL AND GENDER IDENTITY DISORDERS  .GENDER IDENTITY DISORDERS. Present when a person feels trapped in a body that is the “wrong” sex, that does not match his or her innate sense of personal identity. (Gender identity is independent of sexual arousal patterns).  Biological Influences  Not yet confirmed, although likely to involve prenatal exposure to hormones  Hormonal variations may be natural or result from medication
  • GENDER IDENTITY DISORDERS  Psychosocial Influences  Gender identity develops between 1 ½ and 3 years of age  “Masculine” behaviors in girls and “feminine” behaviors in boys evoke different responses in different families  Treatment  Sex reassignment surgery; removal of breasts or penis; genital reconstruction  Requires rigorous psychological preparation and financial and social stability  Psychosocial intervention to change gender identity  Usaully unsuccessful except as temporary relief until surgery
  • PARAPHILIAS  CAUSES  Preexisting deficiencies  In levels of arousal with consensual adults  In consensual adult social skills  Treatment received from adults during childhood  Early sexual fantasies reinforced by masturbation  Extremely strong sex drive combined with uncontrollable thought processes.
  • PARAPHILIAS  TREATMENT  Covert sensitization. Repeated mental reviewing of aversive consequences to establish negative associations with behavior.  Relapse Prevention. Therapeutic preparation for coping with future situations.  Orgasmic Reconditioning. Pairing appropriate stimuli with masturbation to create positive arousal patterns.  Medical. Drugs that reduce testosterone to suppress sexual desire; fantasies and arousal return when drugs are stopped.
  • SEXUAL DYSFUNCTIONS  SEXUAL DYSFUNCTIONS CAN BE:  Lifelong: Present during entire sexual history  Acquired: Interrupts normal sexual pattern  Generalized: Present in everyday encounter  Situational: Present only with certain partners or at certain times
  • SEXUAL DYSFUNCTIONS  PSYCHOLOGICAL CONTRIBUTIONS  Distraction  Underestimates of arousal  Negative thoughts processes  SOCIOCULTURAL CONTRIBUTIONS  Erotophobia, caused by formative experiences of sexual cues as alarming  Negative experiences, such as rape  Deterioration of relationship
  • SEXUAL DYSFUNCTIONS  BIOLOGICAL CONTRIBUTIONS  Neurological or other nervous system problems  Vascular disease  Chronic illness  Prescription medication  Drugs of abuse, including alcohol  PSYCHOLOGICAL AND PHYSICAL INTERACTIONS  A combination of influences is almost always present  Specific biological predisposition and psychological factors may produce a particular disorder
  • TREATMENT OF SEXUAL DYSFUNCTIONS  PSYCHOSOCIAL. Therapeutic program to facilitate communication, improve sexual education, and eliminate anxiety. Both partners participate fully.  MEDICAL. Almost all interventions focus on male erectile disorder, including drugs, prostheses, and surgery. Medical treatment is combined with sexual education and therapy to achieve minimum benefit.