gender identity

1. SEXUAL DYSFUNCTION,
PARAPHILIA AND
IDENTITY DISORDER
OLANIYI A.C

2. Outline
Introduction
Sexual Dysfunction
Disorders of sexual preference
Sexual orientation
Disorders of gender identity
Conclusion

3. Introduction
Human sexuality is the capacity to have erotic experiences
and responses.
Why and how people express themselves as sexual beings
with biological, psychological and social correlates:
◦ Anatomical sex
◦ Gender identity
◦ Sexual orientation
◦ Gender role

4. Determinants of sexual behaviour:
Biological:
◦ Chromosomes and anatomical sex, hormones,
◦ Brain structures (amygdala, INAH-3, pleasure centre)
Psychological:
◦ Freudian phallic stage – identification with same-sex parent,
◦ Gender identity and stability,
Social:
◦ Societal sanctions,
◦ Religious mores.

5. Sexual orientation: Various aspects of sexual attraction towards
members of the opposite or same sex.
Sexual dysfunction: Impaired or dissatisfying sexual enjoyment or
performance.
Abnormalities of sexual preference: Unusual means or objects of
sexual gratification.
Gender identity: person’s sense of ‘maleness’ or ‘femaleness’.

6. Classification
Shorter
Oxford
Textbook
of
psychiatry.
5
th
Ed.

7. Sexual dysfunction
Various ways in which an individual is unable to participate in a sexual
relationship as they would wish.
In men: Repeated impairment of normal sexual interest and/or
performance.
In women: Repeated unsatisfactory quality of intercourse – usually
completed but without enjoyment.

8. Sexual dysfunction
www.sciencedirect.com

9. SEXUAL RESPONSE:
Phase 1: DESIRE
◦ Sexual fantasies, willingness for sexual activity.
Phase 2: EXCITEMENT
◦ Brought on by stimulation (physiological or psychological).
◦ Characterised by penile erection, vaginal lubrication, hardening of clitoris, thickening of
l. minora, elevated BP, PR and RR.
Phase 3: ORGASM
◦ Peak of desire and release of sexual tension
◦ Characterised by ejaculation, rhythmic contractions of the prostate, seminal vesicles,
lower third of the vagina and uterus; tightening of the ext. and int. anal sphincters.
Phase 4: RESOLUTION
◦ Detumescence – disgorgement.
◦ With orgasm: rapid, well-being, general and muscle relaxation; minutes to hours.
◦ Without orgasm: prolonged, irritable.
◦ Does not occur in women.

10. upcpsych1-winter2010-topic8.wikispaces.com

11. Epidemiology
Mercer et al (2003) found that in a sample of UK respondents aged 16-44
years, commonest disorders were lack of sexual interest and orgasm
disorders: F>M.
40% and 33.3% of men and women respectively had a current sexual
problem. Commonest were erectile dysfunction, premature ejaculation,
vaginal dryness and infrequent orgasm

12. General causes
Low sex drive: Hormonal factors.
Anxiety:
◦ Performance anxiety in first timers.
◦ Previous unpleasant sexual experience.
◦ Failure to resolve Oedipal conflict.
Physical illness/Surgical diseases:
◦ DM, hyperthyroidism, myxedema, Gynae infections, MI, COPD, Renal failure, CVD.
◦ Mastectomy, colostomy, oophorectomy, episiotomy, amputation.
Medication: Therapeutic or substances of abuse.

13. General aspects of management:
◦ Hx: What, Where, Course, Social interaction (specific and general),
knowledge of techniques, Mental and physical illness.
◦ Examination: MSE and physical.
◦ Investigations
◦ Treatment:
◦ Couple therapy
◦ Sex therapy: Rx together, communication, education, graded tasks
(sensate focusing)

14. Desire
Lack or loss of sexual desire
◦ F>M
◦ Lack: has been present since onset of sexual activity. Usually
global – biologically low drive or homosexual orientation in
heterosexual context.
◦ Loss: occurred following a period of normal sexual desire.
Global – medical or psychiatric illness, medication or
surgery; or situational – relationship problems.

15. Management:
Individual psychotherapy to address issues with patient such
as feelings of guilt, poor self-esteem, homosexual impulses,
etc.
Couples therapy may be indicated if due to marital conflict.
Testosterone, apomorphine.

16. Sexual aversion
◦ ‘Positive’ aversion to genital contact with partner. Persistent and severe enough
to preclude any genital contact with partner.
◦ Similar aetiology with lack of sexual desire.

17. Arousal
Female sexual arousal disorder
◦ Usually due to reduced vaginal lubrication which may be due to:
◦ Inadequate foreplay, lack of sexual interest, anxiety about intercourse,
post menopause.
◦ Treatment: Sildenafil citrate*.
Male erectile disorder (erectile dysfunction)
◦ Inability to reach an erection or to sustain it long enough for satisfactory
coitus.
◦ Primary: low sexual drive and/or anxiety about performance.
◦ Secondary: Psychological: Diminishing drive in middle-age, anxiety,
depression, loss of interest in partner or Medical conditions especially
vascular disease.

18. Management:
◦ Hx: Previous functioning, Partner specificity, Early morning erection or
during masturbation, drugs (recreational/therapeutic).
◦ Investigation:
◦ Rigiscan (psychogenic vs neurological),
◦ Doppler USS, intra-cavernosal prostaglandin (vascular disorders).
◦ Treatment:
◦ Treat reversible causes.
◦ Cognitive therapy, psychodynamic therapy.
◦ Pharmacotherapy: Phosphodiesterase inhibitors – Sildenafil (viagra).
◦ Intracavernosal injections: papaverine, alprostadil.
◦ Vacuum devices.
◦ Microsurgery (revascularization of corpora cavernosa), penile
implants.

19. http://www.nature.com/ijir/journal/v16/n5/fig_t
ab/3901188f1.html
http://www.google.com.ng/imgres?imgurl=http://www.anactivelife.com/images/
products/encore_standard_manual_vacuum_erection_device_primary_.
Rigiscan
Vacuum device

20. http://edlogs.blogspot.com/2007/09/penile-implants-for-
erectile.html
http://treatmenterectiledysfunction.com/
Inflatable penile implants for treating erectile
dysfunction

21. Orgasm
Female orgasmic dysfunction:
◦ Failure to reach orgasm.
◦ Due to: Low sexual drive, poor technique by partner, relationship difficulties,
depression, physical illness, past sexual abuse, medication.
◦ Treatment: Sex therapy, graded self-stimulation, vaccum device.
Male orgasmic disorder:
◦ Delayed or absent ejaculation during coitus or ejaculation.
◦ Due to: inhibitions about sexual relations, medications – SSRIs, MAOIs or
antipsychotics.

22. Premature ejaculation:
◦ Habitual ejaculation before penetration or soon after such that the
partner has not gained pleasure. Younger men more affected
during first intercourse.
◦ Cause: Sexual inexperience perpetuated by fear of failure.
◦ Treatment:
◦ Squeeze technique
◦ Quiet vagina
◦ Start-stop technique
◦ Sensate focusing
◦ Sex therapy
◦ SSRIs, Clomipramine – last resort, usually in combination with above.

23. Sexual pain disorders
Dyspareunia:
◦ Pain on intercourse.
◦ After partial penetration: impaired lubrication, scars, spasms.
◦ After deep penetration: pelvic pathology – endometriosis, PID, ovarian cysts/tumors.
Vaginismus:
◦ Spasm of vagina causing pain during intercourse, in the absence of a
physical lesion.
◦ May prevent consummation, phobia of penetration, may be associated with guilt about
relationship.
• Treatment: Sex therapy, cognitive therapy, psychodynamic therapy.
Pain on ejaculation: Uncommon, usually due to urethritis
or prostatitis.

24. Disorders of sexual
preference
Characterised by abnormalities of the object or means of
sexual excitement to the exclusion of ‘normal’ sexual
intercourse.
Initially seen as moral offences, medicalized by works of
Richard von Krafft-Ebing (Psychopathia sexualis, 1886) and
Havelock Ellis.
Are not common, few epidemiological studies have been
carried out.

25. Aetiologies:
◦ Not fully understood, however various hypotheses:
◦ Biological:
◦ Little evidence for genetic basis.
◦ Temporal lobe dysfunction.
◦ Psychological:
◦ Conditioning.
◦ Psychoanalytic.
◦ Social:
◦ Difficulty with interacting with adults of opposite sex.
◦ Inhibition of normal sexual behaviour.

26. Related concepts :
◦ Deviance
◦ Harm
◦ Suffering
General aspects of management:
◦ Presentation:
◦ Direct
◦ Indirect (sexual dysfunction).

27. ◦ Hx:
◦ Details of sexual behaviour: normal and abnormal, past and
current, fantasies, other paraphilias.
◦ Exclude mental disorders : Dementia, mania, depression, alcohol
use.
◦ Factors increasing the behaviour,
◦ Motivation for seeking treatment.
◦ Tests: Penile plethysmography, polygraph, Abel’s
assessment of sexual interest (AASI).

28. ◦ Treatment:
◦ Agree aims: Adjustment vs control or giving up behaviour.
◦ Adjustment: identify associated problems and solve.
◦ Control: Improve quality of normal sexual relationships, treat any
sexual inadequacy.
◦ Anticipate problems from abstinence – improve leisure.
◦ Cognitive therapy – avoid paraphilic fantasies or modify progressively,
encourage hetero- (homo-) sexual fantasies.
◦ Behavioural treatments: Aversion therapy, relapse prevention.
◦ Hormonal – Androgen antagonists (Cyproterone,
medroxyprogesterone), LHRH agonists.

29. Types of paraphilias
Abnormal object of preference: (in)animate .
Fetishism
◦ Inanimate objects (underwear) or parts of the body not directly
related to sex (hair, feet - partialism) – when it takes precedence
over normal sexual intercourse.
◦ M>F, may be homosexual or heterosexual.
◦ May involve an attribute eg missing limbs – apotemnophilia.
◦ Poor outcome in single, shy, solitary men and increased conflicts
with the law.

30. Transvestic fetishism
◦ Cross-dressing to derive sexual excitement.
◦ M>F.
◦ Starts around puberty, more in younger people, reduces with age.
◦ No confusion with gender identity.
◦ Outcome: reduces in middle age, may convert to transsexualism.

31. Pedophilia
◦ Repeated sexual activity (or fantasy) with pre-pubertal children.
Different from statutory rape.
◦ M>F, hetero- or homosexual, onset is usually in early life.
◦ Marked incapacity for relationship with adults.
◦ Female victims usually 6-12 years, boys usually older. Usual activity is
masturbation or fondling rather than penetration.
◦ Differentials: exhibitionism, dementia, learning disability, alcoholism.
◦ Poor response to treatment.

32. Zoophilia (Bestiality, bestiophilia)
◦ Object of sexual arousal is animals, uncommon.
Necrophilia
◦ Dead bodies.

33. Abnormalities of the sexual act
Sadism
◦ After Marquis de Sade.
◦ Sexual arousal from habitually from inflicting physical or psychological
pain on others. May be symbolic or actual. Beating, whipping,
humiliation.
Masochism
◦ After Leopold von Sacher-Masoch.
◦ Sexual excitement (preferred/exclusively) through the experience of
suffering/humiliation.

34. Exhibitionism
◦ Repeated exposure of genitals to unsuspecting
individuals, without attempts at further sexual activity.
◦ M>F, persistent vs episodic, preceded by tension,
masturbate during or after exposure.
◦ 2 personality types:
◦ Inhibited, resist, guilt, flaccid penis.
◦ Aggressive, antisocial traits, erect penis.

35. Voyeurism (Peeping Tom)
◦ Observing the sexual activity of others as the preferred means of sexual
excitement. Includes undressing and bathing.
◦ No attempt at further sexual activity.
◦ Usually hide from victims.
Auto-erotic asphyxiation (asphyxiophilia, hypoxyphilia)
◦ Inducing anoxia to heighten sexual arousal while masturbating via
partial strangulation.
Frotteurism
◦ Preferred means of sexual excitement is rubbing genitalia against or
fondling breasts of unwilling participant. Usually strangers, in crowded
places.

36. Corprophilia
◦ Preferred means of sexual arousal is from watching or thinking about the act of
defecation.
Corprophagia
◦ Sexual arousal is via eating faeces.
Sexual urethrism
◦ Sexual arousal is from stimulating the urethra, F>M.
Urophilia (water sports)
◦ Sexual arousal from watching the act of urination, being urinated upon or
drinking urine.
Telephone scatalogia
◦ Sexual arousal from making obscene phone calls talking about sexual activity.
Sexual infantilism
◦ Sexual arousal from being treated like an infant – being bottle-fed, having
pampers worn.

37. Sexual orientation
Various aspects of sexual attraction towards same or opposite sex.
A continuum between homosexuality and heterosexuality – Kinsey.
Other suggested attributes include:
◦ sexual fantasies, sexual behaviour, emotional preference, social preference, life
style preference and self-identification.
10% of men had been exclusively homosexual for at least 3 years, while 4%
had been homosexual all their lives (1948), cf 4% of women.
Later studies (1995) found rates of 2.8% and 1.4% in men and women
respectively.

38. Kinsey scale
Rating Description
0 Exclusively heterosexual
1
Predominantly heterosexual, only incidentally
homosexual
2
Predominantly heterosexual, but more than incidentally
homosexual
3 Bisexual.
4
Predominantly homosexual, but more than incidentally
heterosexual
5
Predominantly homosexual, only incidentally
heterosexual
6 Exclusively homosexual
X Asexual, Non-Sexual

39. http://www.gay.net/sites/gay.net/files/imce/kn_big2.jpg

40. Klein’s sexuality grid
Past (entire life up until a year
ago)
Present (last 12 months) Ideal (what would you like?)
A). Sexual Attraction: To
whom are you sexually
attracted?
B). Sexual Behaviour: With
whom have you actually
had sex?
C). Sexual Fantasies: About
whom are your sexual
fantasies?
D). Emotional preference:
Who do you feel more
drawn to or close to
emotionally?
E). Social preference:
Which gender do you
socialize with?
F). Lifestyle preference: In
which community do you
like to spend your time? In
which do you feel most
comfortable?
G). Self-identification: How
do you label or identify
yourself?

41. Epidemiology
Regarding sexual orientation, a 2013 study on 18–
44-year-olds in the US showed that 92% of women
and 95% of men said they were ‘heterosexual or
straight’; 1.3% of women and 1.9% of men said
they were ‘homosexual, gay, or lesbian’; 5.5% of
women and 2.0% of men said they were bisexual;
and 0.9% of women and 1.0% of men said ‘don’t
know’ or declined to answer (Copen et al., 2016).

42. Determinants of sexual orientation: Not fully understood.
◦ Biological:
◦ Twin studies: MZ>DZ.
◦ Genetic: Chr. Xq28 – not consistent.
◦ Birth order.
◦ In-utero hormonal environment.
◦ Sexually dimorphic nuclei – INAH 3.
◦ Psychological:
◦ Poor relationships with parents: distant father, over-protective
mothers.

43. Previously viewed as a disorder of sexual preference,
viewed as alternative lifestyle following work by Evelyn
Hooker (1974).
Removed from DSM in 1978 and much later from ICD.
Vestige: ‘Ego-dystonic sexual orientation’, when an
individual is distressed by their sexual orientation and
wish to change it.

44. Problems include:
◦ Psychological:
◦ Bullying, suicide and DSH (especially in adolescents),
depression, anxiety, internalized homophobia, psychoactive
substance use, sexual dysfunction (in heterosexual context).
◦ Social:
◦ Social isolation, discrimination.
◦ Biological:
◦ Increased risk of STIs (poor access to sexual
education/treatment options).

45. Disorders of Gender
Identity

46. Transsexuality:
◦ When an individual is convinced he/she is of the gender
opposite to that indicated by their chromosomes. Wish to
alter bodily appearance and genitalia and live as member of
opposite sex.
◦ Transsexual male – born female and vice versa, or female to
male transsexual.
◦ Prevalence of about 1 in 10,000 born males and 30,000 born
females (Kesteren et al, Netherlands, 1996).

47. Characteristics
◦ Usually starting before puberty, transsexuals have a
strong conviction that they were born the wrong sex.
◦ Cross-dressing (cf transvestic fetishism).
◦ Request plastic surgery to alter body and genitalia e.g.
breast, penectomy, orchidectomy, vagina construction.
◦ Depression common and deliberate self-harm.

48. Aetiology:
◦ No evidence for genetic basis or early upbringing.
◦ In-utero hormonal exposure, but no consistent
evidence.
◦ Brain structure: Sexually dimorphic nuclei – bed
nucleus of the stria terminalis is larger in men than
women, ?similar in MTF and women (Zhou et al, 1995).
◦ Transition from transvestic fetishism.

49. Treatment: follows the Harry Benjamin Int’l Gender Dysphoria
Association document.
◦ Agree a plan
◦ Need to go gradually.
◦ Counselling
◦ Alternative options and implications of change.
◦ ‘Real Life experience’
◦ Getting accustomed to living as opposite sex for 1 year,
◦ Full time employment/studentship.
◦ Hormonal treatment (>18, understand implications of hormone
therapy, completed 3 months of the real life experience or
counselling).
◦ Estrogen, Androgens.

50. ◦ Surgery
◦ MTF – Mammoplasty, penectomy, orchidectomy,
creation of vagina-like structure (skin (penile or
other, int.).
◦ FTM – mastectomy, ovariectomy, phalloplasty.
◦ Support for family.
*Gender Identity Disorder in Children
◦ More concern about effeminate boys than masculine
girls. Some boys later develop ‘male’ interests others
grow into homosexual men.

51. Conclusion
•Human sexual behaviour is a complex phenomenon with
various biopsychosocial determinants.
•Disorders associated with it are seldom discussed openly
in our environment due to the cultural perception of sexual
matters. However they straddle psychiatric, medical and
surgical practice.
•Hence, it is important to have not just a basic knowledge of
these disorders but the tactfulness and lack of prejudice
required to elicit them.

52. THANK YOU