Chapter 10: Sexual Disorders and Gender Identity Disorder
Gender: psychological condition of being female, male, graduations of both
Sex: biological condition of being female or male
Gender Role: behaving in a way that is typical of females of males
->Enactment of gender stereotypes, gender schemas, doing gender
Gender Identity: sense of maleness/femaleness, graduation of both
Gender Dysphoria: Marked incongruence with one’s experienced and expressed
Gender and assigned gender
-Discontent with biological sex
-Desire to live in felt gender role
-Desire for physical characteristics of opposite sex
Transgender: A person whose gender is different from their biological sex
-Adopts the felt gender role
Transsexual: Person whose phenotypic sex (physical sexual characteristics) is
Altered through surgery and/or hormone treatments to match their
Gender identity
Intersexed: a person who’s born with a mix of biological traits typical of both sexes
-A person having a disorder of sexual development
Fa’afafine: Third gender role in Samoan culture
-Biological males living in the female role, sexually attracted to men
Two-Spirit: Third gender (mixed gender identity) among First Nations People
Genderqueer: Person with varying stereotypical gender combinations and chooses
Not to adopt either identity
3 Kinds of Sexual Behaviour Disorder:
1. Gender Identity Disorder: experiences psychological dissatisfaction with
his or her biological sex.
-Not specifically sexual but disturbance in person’s sense of identity
2. Sexual Dysfunction: difficult to function adequately during sex
3. Paraphilia: sexual arousal occurs primarily in the context of inappropriate
objects or individuals
Transsexuality Characteristics
a) Male-to-Female Transsexual (MTF)
Biological male who identifies as a woman
Can be attracted to women (lesbian) or men (heterosexual)
Significant majority of lesbian-identified MTF have a history of
autogynephila: sexual attraction to the image of oneself as a woman
b) Female-to-Male Transsexual (FTM)
Biological female who identifies as a man
Can be attracted to women (heterosexual) or men (gay) Etiology of Gender Variation
-No clear psychological theory of gender incongruity
-Extrapolation from hormonal/biological studies in animals and from
DSDs/Intersexed to gender variant people
Suggest that gender is associated with early/prenatal hormonal events that
shape brain development sexual attractions, and gender congruence
Intersexed brain theory: some event causes the brain to develop in male-typical or
female-typical ways
Homosexual have a 39% greater chance of being left/mixed handed
Hypothalamic nucleus -> bed of nucleus of the stria terminalis differences in
structure volume and neuron count
Smaller in MTFs than natal males
1 FTM greater than natal females
Berglund (2008)
MTFs (lesbian) activation to same and opposite-sex pheromones different
from natal heterosexual men, more similar to natal heterosexual women
Gizewski et al (2009)
Brain activation during erotic stimuli similar in MTFs as natal women
Development of Sexual Orientation (Gene & Gender variations)
-Studies show that there is a heritability of gender-related behavior and gender
dysphoria in child and adolescent twin samples
Possible gene for homosexual orientation = X chromosome
50% of monozygotic twins, 16%-22% dizygotic twins
-Environmental factor and biological vulnerability contributes
-Variations in genes that code sex hormones, androgens & estrogens (testosterone)
Androgen receptor gene of MTFs impairs androgen utilization
Variations in androgen & estrogen receptor, and related genes in FTMS
Gender Differences
-Higher reports of men than women who masturbate (80% vs. 48%)
-Men endorse more sexual fantasies than women except for erotic garments
-Casual premarital sex more permissively acceptable by men (gap is getting smaller)
Women tend to report passionate/romantic feelings as an integral part of
their sexuality and openness to sexual experience
Men feel power, independence, and aggression as well as passion and
openness and generally do not possess negative beliefs reflecting self-
consciousness, embarrassment or inhibition
½ of adolescent males & ¼ of females report two or more sexual partners in
a year
Oral contraceptive use (84%-90%)was more common than condom use
(64%-80%) ->STD rates are rising while pregnancy rates have decreased
Cultural Differences
a) Sambina, New Guinea:
-Believe semen to be an essential substance for growth and development for
young boys in the tribe and it is not produced naturally (cannot produce
spontaneously)
-All young boys in the rive around 7 become semen recipients by engaging
exclusively in homosexual oral sex with teenage boys and later on switch roles
-Only oral sex is permitted; no masturbation allowed
-They are then later expected to marry and become exclusively heterosexual
b) Munda, India
-Adolescents and children live together (both male and female)
-Sexual activity -> mostly of petting and mutual masturbation (heterosexual)
Gender Identity Disorder : person’s physical gender is inconsistent with that
person’s sense of identity and they feel trapped in their own body. The primary goal
is not sexual but rather the desire to live life openly like others with that gender.
1) A strong and persistent cross-gender identification (more than a desire)
Repeated state of desire to be, or insisting that they are the opposite sex
Boys -> preference to cross –dress or simulate female attire
Girls -> insisting on wearing stereotypical masculine clothing
Strong/persistent preferences for cross-sex roles in make-believe play or
fantasies of being the other sex
Intense desire to participate in the stereotype activities of other sex
Strong preference for playmates of the other sex
Adults/Adolescents: symptoms such as a stated desire to be the other sex,
frequent passing as the other sex, desire to life or be treated as the other sex,
or the conviction of having the typical feelings/reactions of the other sex
2) Persistent discomfort with his or her sex or sense of inappropriateness in the
gender role of that sex (want to get rid of physical characteristics)
Boys: penis/testes are disgusting or will disappear or better without
them, avoid rough and tumble play and rejection of male stereotypes
Girls: rejection of urinating in a sitting position, assertion that she has
or will grow a penis, she does not want to grow breasts or menstruate
or avoid female clothing
Adults: preoccupation with getting rid of primary/secondary sex
characteristics (request for hormones, surgery, physical altercations)
or belief that they were born in the wrong sex
3) The disturbance is not concurrent with a physical intersex condition
EX: hermaphrodites: born with ambiguous genitalia 4) Disturbance causes clinically significant distress or impairment in social,
occupational or other important areas of functioning
Gender identity is independent of sexual arousal patterns
EX: heterosexual women before surgery become gay men after surgery
“Treatment” of Gender Dysphoria
-Focuses on ways to resolve gender dysphoria counseling/support process
-Follows World Professional Association for Transgender Health Standards of Care
Psychological & physical evaluation:
->Rule out mental disorder, physical factors
Real-life experience
Hormone replacement therapy
Sex reassignment surgery/adjunct surgeries
->No longer required in Ontario for gender change on birth certificate
-During counseling, explore possibilities of:
Occasional living in the felt gender role
Full-time living
Hormone therapy
Sex reassignment surgeries
DOESN’T focus on accepting gender role associated with biological sex
Sexual dysfunction : difficulty-achieving arousal during sexual interactions
Due to a) psychological factors b) combination with medical condition
Can be either lifelong or acquired
Generalized (occurring every time) or Situational (certain partners or times)
28% of women and %18 men experience sexual dysfunction
Sexual Desire Disorders
Hypoactive Sexual Desire Disorder: little/no interest in any sexual activity
a. Persistently or recurrently deficient/absent sexual fantasies and desire for
sexual activity.
b. Disturbance cause marked distress or interpersonal difficulty
c. Dysfunction is not better accounted for but another disorder and is not due
exclusively to the direct physiological effects of a substance or a general
medical condition
-50% of patients complain of hypoactive sexual desire with more frequency found in
women while men more often reported for erectile dysfunction
-Patients with this disorder rarely have sexual fantasies, seldom masturbate and
hardly engage in intercourse
Sexual Aversion Disorder: thought of sex or touch may evoke fear, panic, disgust
a. Persistent/recurrent extreme aversion to, and avoidance of almost or all
genital sexual contact with a sexual partner b. Disturbance causes marked distress or interpersonal difficulty
c. The sexual dysfunction is not better accounted for by another disorder
Sexual Arousal Disorders
Female sexual arousal disorder/Male erectile disorder: although having
frequent sexual urges and fantasies and a strong desire to have sex, their problem is
in become physically aroused
a. Persistent/recurrent inability to attain or maintain adequate lubrication or
erection as a response of sexual excitement until completion of sex
b. Disturbance causes marked distress or interpersonal difficulty
c. Dysfunction is not better accounted for but another disorder and is not due
exclusively to the direct physiological effects of a substance or a general
medical condition
-In women, arousal and lubrication may decrease at any time but for men, such
problems tend to accompany aging
-Situations where: full erections are possible during masturbation and a partial
erection during attempted intercourse but with insufficient rigidly to allow
penetration
-40% of 40 year-old men and 70% of 70 year-old men have impairment
Criticism of the current definition of female arousal disorder
Focuses too much on genital events (ex: lubrication difficulties) and instead
should focus on women’s subjective arousal
Studies show that women with arousal disorders often show normal vaginal
responding to erotic movies which reporting low subject excitement
Orgasm Disorders
Inhibited Orgasm: inability to achieve an orgasm despite adequate sexual desire
and arousal is commonly seen in women but rare in men
25% of women report difficulty reaching orgasm
Only 50% of all women experience reasonably regular orgasms during sexual
intercourse
Globally, 5% of men report the inability to achieve orgasms
Premature Ejaculation: ejaculation that occurs well before the man and partner
want it to
9% of all men report a sexual dysfunction involving premature ejaculation
Typically climax no more than 1-2 minutes after penetration
Behavioral (ex: regularity of premature ejaculation, Emotional (ex: worry or
concern for), Efficiency (ex: perceiving that they have little control
Appears more often to inexperienced women with less education and lower
frequency of intercourse Sexual Pain Disorders
Dyspareunia: high sexual desire/drive but pain of intercourse is extremely severe
a. Persistent or recurrent genital pain associated with sexual intercourse in
either a male and female
b. Disturbance causes marked distress or interpersonal difficulty
c. Dysfunction is not caused exclusively by vaginismus or lack of lubrication, is
not better accounted for but another disorder and is not due exclusively to
the direct physiological effects of a substance or a general medical condition
-Only diagnosed if no medical reasons for pain can be found
-Degree of pain found in women similar to depressive/anxious symptoms and can
be associated with marital adjustment problems, hostility and psychotic symptoms
-Rarely seen in clinics but estimates range from 1-5% of men and 10-15% in women
Treatment:
Should be approached from a pain-management perspective
Focus on the patient’s chronic pain, impact of the dyspareunia on the couple’s
relationship and any associated psychological effects
Vaginismus: spasm reaction of vagina occurs during sexual intercourse
a. Persistent/recurrent involuntary spasm of the musculature of the outer third
vagina that interferes with sexual intercourse
b. Disturbance causes marked distress or interpersonal difficulty
c. Dysfunction is not better accounted for but another disorder and is not due
exclusively to the direct physiological effects of a substance or a general
medical condition
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