Lecture 8 sexual and gender identity disorders

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.

 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.

 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.

 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)

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.

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

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

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
 C. The sexual dysfunction is not better accounted for
by another Axis I Disorder (except another sexual
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
 Specify

 Male
 A. Persistent or recurrent inability to attain, or to
maintain until completion of the sexual activity, an
adequate erection.
 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)

 Specify type:
 Lifelong type
 Acquired type
 Specify type:
 Generalize type
 Specify

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.

 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
 Specify

 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.

 C. The orgasmic dysfunction is not better accounted for
by another Axis I Disorder (except another sexual
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
 Specify

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.

 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
 Specify
DSM-IV-TR TABLE 10.6 DIAGNOSTIC CRITERIA
FOR PREMATURE EJACULATION

CRITERIA FOR SEXUAL PAIN DISORDER
 Dyspareunia
 A. Recurrent or persistent genital pain associated
with sexual intercourse in either a male or a female.
 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.

 Specify type:
 Lifelong type
 Acquired type
 Specify type:
 Generalize type
 Specify

 Vaginismus
 A. Recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that
interferes with sexual intercourse.
 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.

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.

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

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)

VOYEURISM AND EXHIBITIONISM
 Voyeurism
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

VOYEURISM AND EXHIBITIONISM
 Exhibitionism
behaviors involving the exposure of one’s genitals to
an unsuspecting stranger.
sexual urges or fantasies caused marked distress or

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.
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
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
behaviors involving the act (real, not stimulated) or
being humiliated, beaten, bound, or otherwise made
to suffer.
occupational, or other important areas of
functioning.

DSM-IV-TR TABLE 10.13 CRITERIA
PEDOPHILIA
behaviors involving sexual activity with a prebuscent
child or children (generally age 13 years or younger).
sexual urges or fantasies caused marked distress or
 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

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.

Lecture 8 sexual and gender identity disorders

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